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Advisory  Editor 

Charles  E.  Rosenberg 

Professor  of  History 

University  of  Pennsylvania 


THE 


CAUSATION,  COURSE,  AND  TREATMENT 


REFLEX  INSANITY  IN  WOMEN 


BY 


HORATIO  ROBINSON  STORER,  M.  D.,  LL.  B. 


m 


o^RNO  ^REss  &  The  A(ew  York  Times 


New  York     1972 


Reprint  Edition  1972  by  Amo  Press  Inc. 

Reprinted  from  a  copy  in 

The  Library  of  The  College  of 

Physicians  of  Philadelphia 

LC#     71-180592 
ISBN  0-405-03974-3 

Medicine  and  Society  in  America 

ISBN  for  complete  set:     0-405-03930-1 

See  last  pages  of  this  volume  for  titles. 

Manufactured  in  the  United  States  of  America 


THE 


CAUSATION,  COURSE,  AND  TREATMENT 


REFLEX  INSANITY  LN  WOMEN. 


BY 

HORATIO  ROBINSON  STORER,  M.  D.,  LL.  B., 

OF  BOSTON, 

Burgmn  to  8c.  Eliubeth'i  iind  Si.  Francit't  Hoipitala  for  Women  ;  Contulting  Surgeon  to  th«  Carnej  (Gentnl) 

Hospital ;  formerly  Assistant  in  Obstetrics  and  Medical  Jurisprudence  in  Harvard  Unirersity,  Frofeaior 

of  Obstetrics  and  tbe  Diseases  of  Women  in  Berlcshire  Medical  College,  and  Pb/sician  to  tbe  Boston 

Ljtng-in'Hospital ;  lace  Vice-President  of  tbe  American  Medical  Association  ;  Member  of  tht 

GjDSecological  Society  of  Boston,  the  New  York  Medico-Legal  Society,  tbe  Obstetrio 

aikd  Mcdico-Cbirurgical  Societies  of  Edinburgh  ;  Correspouding  Member  of  th« 

Obstetrical  Society  of  Berlin  ;    Honorary  Member  of  the  LouIstUU 

Obat«ui«al  Society,  and  of  tli«  CaoadiaD  Medical  AsweiatioB. 


Sublatd  causd,  tollitur  fffectus. 


BOSTON: 
LEE    AND    SHEPARD,  PUBLISHERS. 

NEW  YORK: 

LEE,  SHEPARD   AND  DILLINGHAM. 

1871. 


Entered,  according  to  Act  of  Congress,  in  the  year  1870, 

By   lee  AKD  SHKPAUl), 

In  the  Office  of  the  Librarian  of  Congress,  at  Washington. 


STEREOTYPED  AT   THB 

BOSTON    STKRF.OTYPE    FOUNDBT, 

19  Spring  Lane. 


MEMBERS  OF  THE  GYNiECOLOGICAL  SOCIETY 

OF     BOSTON, 

THOUGHTFUL,  WORKING,  FEARLESS  GENTLEMEN, 
ALREADY  A  POWER  IN  THE  LAND, 

IS  AFFECTIONATELY   INSCRIBED. 


PREFATORY    NOTE. 


The  following  pages  were  communicated  to  the  American 
Medical  Association  in  1865,  at  its  session  in  Boston,  and 
were  printed  in  its  Transactions  for  that  year.  The  writer 
has  been  requested  to  republish  his  memoir  by  physicians 
interested  in  gynaecology,  who  have  desired  a  copy  in  a  sep- 
arate form  for  their  book-shelves,  or  have  thought  the  topic 
deserving  more  general  attention ;  and  he  was  duly  author- 
ized to  do  so  by  a  formal  vote  of  the  Association,*  at  its 
session  at  Cincinnati  in  1867. 

Many  causes  have  combined  to  prevent  accedence  to  the 
wish  of  his  friends  and  the  repeated  request  of  his  publish- 
ers, chief  among  them,  perhaps,  the  feeling  that,  as  he  had 
so.wn  the  seed,  it  should  be  for  others  to  develop  the  tender 
growth  of  a  better  practice.  He  has  cherished  the  lingering 
hope,  moreover,  that  he  might  some  time  find  leisure  to  pre- 
pare a  work  upon  this  interesting  subject  of  reflex  insanity 
more  worthy  its  intrinsic  and  practical  importance. 

That  leisure,  however,  has  not  yet  arrived ;  and  the  publi- 
cation by  Professor  Louis  Mayer,  of  Berlin,  in  the  last  vol- 
ume of  the  Transactions  of  the  Obstetrical  Society  of  that 
city,  of  an  elaborate  paper  upon  the  relations  of  the  fe- 

*  Transactions  of  the  Association,  vol.  xviii.,  1867,  p.  43.  By  its  constitution, 
all  scientific  communications  made  to  the  Association  become  its  exclusive  prop* 
erly,  and  cannot  be  published  by  their  authors  without  express  permission. 

(S) 


6  PREFATORY    NOTE. 

male  sexual  organs  to  mental  disease,  has  seemed  to  afford 
a  suitable  moment  for  simultaneously  presenting  the  two 
memoirs  to  the  medical  public  in  this  country.*  It  will  be 
perceived  that,  approaching  the  subject  from  a  somewhat 
different  stand-point,  and  in  entire  ignorance  that  he  had 
been  anticipated  in  the  investigation  by  several  years,  Pro- 
fessor Mayer  affords  unanswerable  proof  of  the  correctness 
of  every  point  made  in  the  following  pages. 

The  writer  has  preferred,  in  view  of  his  inability  to  revise 
and  extend  the  paper,  to  make  no  material  changes  in  it 
whatsoever. 

Hotel  Pelham,  Boston,  i  November,  1870. 

•  A  translation  of  Prof.  Mayer's  memoir,  by  Dr.  George  H.  Bixby,  with  notes 
by  Dr.  Storer,  will  be  found  in  the  Journal  of  the  Gynacological  Society  of 
Boston,  commencing  with  the  number  for  May,  1870.  Discussions  upon  the  gen- 
eral subject  of  insanity  in  women  have  been  held  at  several  of  the  meetings  of 
the  Society,  reports  of  which  have  also  been  published  in  its  JoumaL 


CONTENTS. 


PAOI 

I.    Selection  of  Special  Topic 9 

II.    Point  previously  attained 21 

III.  Work  to  be  done 30 

IV.  The  Brain  the  Seat  of  Insanity,  not  always  of  its 

Cause 36 

V.  Explanations  of  distant  Causation 62 

VI.  Causation  of  Insanity  often  Pelvic  in  Women.     .     77 

VII.  Rationale  of  Pelvic  Causation  of  Insanity.      .     .  127 

VIII.  Indications  of  Treatment 157 

(7) 


THE  CAUSATION,  COURSE,  AND  TREATMENT 
OF  REFLEX  INSANITY  IN  WOMEN. 


I.  —  Selection  of  special  Topic. 

It  was  decided  at  the  meeting  of  the  American 
Medical  Association,  held  at  St.  Louis,  in  1854,  to  ^^' 
tablish  a  standing  committee,  annually  to  be  chosen, 
and  regularly  to  report  "  upon  the  subject  of  insanity 
as  it  prevails  in  this  country,  including  its  causation, 
as  hereditary  transmission,  educational  influences,  — 
.physical  and  moral,  —  social  and  political  institutions, 
&c. ;  its  forms  and  complications,  curability,  means 
of  prevention,  &c." 

In  1865,  eleven  years  had  elapsed  since  the  com- 
mittee was  first  appointed,  and  to  that  time  there 
seems  to  have  been  rendered  no  report.  Special 
committees,  it  is  true,  upon  particular  points,  selected 
by  the  Association,  and  connected  with  the  general 
subject  of  insanity,  had  twice  attended  to  the  duties 
assigned  to  them,  preparing  the  excellent  papers  upon 
the  Medical  Jurisprudence  of  Insanit}^,  by  Dr.  Cov- 
entry, of  Utica,  N.  Y.,  and  upon  Moral  Insanity  in 
its  Relations  to  Medical  Jurisprudence,  by  the  late 

(9) 


lO  REFLEX    INSANITY 

Dr.  D.  Meredith  Reese,  of  New  York  city,  —  both 
of  them  rendered  to  the  meeting:  held  at  Washington 
in  1S58,  and  contained  in  the  pubHshed  volume  of 
the  Transactions  of  the  Association  for  that  year.  A 
similar  report  upon  the  Morbid  and  Therapeutical 
Effects  of  Mental  and  Moral  Influences  had  been 
promised  by  Professor  Palmer,  of  Michigan.  As  re- 
gards, however,  the  regular  standing  committee  upon 
insanity,  the  fact  remains  as  stated  :  it  had  uniformly 
failed  to  accomplish  its  work.* 

This  is  the  more  surprising  when  we  consider  to 
what  extent  the  subject  had  already  been  studied  in 
this  country,  the  excellence  to  which  our  general  sys- 
tem of  hospital  arrangement  had  been  brought,  and 
the  eminence  attained  by  many  American  superin- 
tendents. 

These  gentlemen  had  been  freely  placed  upon 
the  committee  appointed  by  the  Association  in  years 
past,  if  not,  indeed,  in  each  previous  instance  selected 
from  them  alone,  and  it  is  a  matter  of  extreme  regret 
that  they  should  not  have  responded  to  the  call ;  for 
there  are  few  subjects  attended  with  the  interest  to 

•  Dr.  Hills,  of  Ohio,  at  that  time  superintendent  of  the  Central  Lunatic  Asy- 
lum at  Columbus,  who  was  charged  with  the  duty  of  reporting  at  the  New  York 
meet'ng,  as  chairman  of  the  committee  on  insan'ty  for  1C64,  was  prevented  from 
fulfilling  that  trust;  among  other  causes,  by  "the  breadth  of  foundation  he 
had  laid  for  an  elaborate  report. "  At  his  request,  he  was  granted  an  extension 
of  time,  with  the  understanding,  however,  that  this  arrangement  did  not  interfere 
with  the  appointment  of  the  new  committee  for  1S65,  which  it  was  understood 
by  the  nominating  committee  was  then  annually  required  by  the  organic  law  of 
the  Association. 


IN   WOMEN.  H 

the  profession  at  large  that  pertains  to  this  of  insani- 
ty ;  few  with  such  important  bearings  upon  the  wel- 
fare of  the  community,  and  its  relations  to  medical 
men,  —  few  with  such  fruitful  fields  for  labor  and 
success. 

It  will  undoubtedly  be  alleged,  that  in  the  fact  that 
the  hospital  superintendents  of  the  several  States  had 
united  themselves  into  a  separate  organization,  —  the 
so-called  Association  of  Superintendents,  meeting  an- 
nually for  purposes  of  conference,  and  publishing  a 
journal  devoted  to  the  interests  of  their  speciality, — 
there  was  enough  accomplished  for  all  the  purposes 
of  science  and  practical  art,  leaving  it  unnecessary  for 
any  annual  contribution  to  either  to  be  made  through 
other  channels.  We,  however,  of  the  profession  at 
large,  can  hardly  acknowledge  the  justice  of  such 
reasoning.  Special  journals,  however  ably  conduct- 
ed, and  with  whatever  extent  of  circulation,  do  not 
reach  every  general  practitioner.  As  well  ought  it 
be  said  that  any  contribution  to  the  science  of  oph- 
thalmology—  which,  of  all  the  departments  of  medi- 
icine,  now  seems  to  boast  the  largest  and  most  enthu- 
siastic number  of  skilled  devotees  —  would  be  out  of 
place  or  unden'alued  with  ourselves,  simply  because 
that  branch  has  now  its  own  national  organization 
and  its  special  journals. 

Every  specialist,  no  matter  what  his  favorite  study, 
whether  insanity,  ophthalmology,  or  the  diseases  of 


12  REFLEX    INSANITY 

women,  owes  his  first  duty  to  the  profession  at  large, 
for  it  is  through  it  that  his  observations  or  his  discov- 
eries must  really  become  effective.  It  is  through 
those  that  apply  upon  the  widest  scale  theories  to 
practice,  and  practice  to  its  ultimate  demonstrations, 
that  the  largest  results  are  to  be  gained  ;  and,  in  this 
matter  of  insanity,  for  every  patient  that  is  carried  to 
an  asylum  for  treatment,  scores  are  treated  in  their 
earlier  stages,  wherein  the  chances  of  success  are  al- 
lowed to  be  infinitely  the  greater,  by  the  profession 
outside  asylum  walls ;  and  for  every  patient  that  is 
ultimately  cured  in  an  asylum,  in  hundreds  the  de- 
rangement threatening  is  warded  off  by  judicious 
general  or  special  treatment  at  home,  or  in  changed 
localities. 

Now,  be  it  distinctly  understood  that  no  man  can 
put  a  higher  value  than  I  do  upon  our  public  hospi- 
tals for  the  insane.  There  are  few  of  the  profession, 
not  directly  connected  with  these  institutions  as  phy- 
sician or  trustee,  who  have  studied  them  more  care- 
fully, or  upon  a  larger  scale,  both  in  their  minute 
details  and  their  comparative  plans  and  methods  of 
management.  I  believe  them  to  be  excellently  con- 
ducted, and  most  of  their  medical  officers  to  be  men 
well  selected,  of  skill,  and  worthy  the  highest  trust. 
The  records  of  the  Association  of  these  gentlemen 
show  the  most  painstaking  and  extended  efforts  at 
improvement,  and  reflect,  as  does  the  Journal  con- 


IN   WOMEN.  £3 

ducted  in  its  behalf,*  much  credit  upon  itself  collec- 
tively, and  its  individual  members.  Had,  however, 
the  Society  of  Superintendents  but  put  itself  into  more 
direct  connection  with  the  General  Association,  of 
which  its  members  were,  and  still  are,  almost  every 
one  of  them  in  fellowship,  it  would  have  effected 
more  towards  establishing  the  high  standard  and  ac- 
complishing the  good  it  has  intended. 

The  opinion  has  prevailed  in  many  quarters  —  it 
has,  to  a  certain  extent,  been  inculcated,  as  in  the 
most  excellent  work  upon  the  medical  jurisprudence 
of  insanity,  by  my  friend.  Dr.  Isaac  Ray  —  that  no 
one  can  possibly  know  much  of  insanity,  or  at  any 
rate  be  accepted  as  of  any  authority  upon  the  subject, 
unless  he  is  a  member,  as  superintendent  or  ex- 
superintendent,  of  this  inner  circle. 

But  a  man  cannot  study  a  special  point  in  medicine 
with  interest,  assiduity,  and  good  faith  for  many  years, 
without  forming  decided  conclusions  thereon.  If, 
moreover,  his  position,  by  accident  or  other  advan- 
tage, has  been  such  as  to  render  him  perfectly  inde- 
pendent of  all  party  or  individual  bias,  nullius  ad- 
dictus  jurare  in  verba  magistri^  these  conclusions 
should  have  the  greater  weight ;  and  if,  in  addition, 
he  approaches  the  subject  from  a  standpoint  compar- 
atively new,  certainly  so  far  as  previous  employment 
of  it  to  attain  a  practical  end  has  been  concerned,  and 
if  he  is  able  to  show  that  measures  which  in  one 

*  The  American  Journa]  of  Insanity,  Utica,  N.  Y. 


14  REFLEX    INSANIT"^ 

quarter,  namely,  in  civil  practice,  are  found  very  ef- 
fective for  cure,  in  another  quarter,  namely,  in  asylum 
practice,  are  as  yet  generally  and  practically  unrecog- 
nized, his  conclusions  should  be  very  apt  to  carry 
with  them  conviction. 

Such,  I  would  respectfully  submit,  is  my  own  posi- 
tion with  regard  to  the  present  report.  It  is  ofiered 
as  a  plain,  straightforward  statement  of  facts,  com- 
mending themselves  to  the  good  sense  of  every  mem- 
ber of  the  profession. 

Upon  the  general  subject  of  insanity  volumes  upon 
volumes  have  already  been  written,  some  of  them  of 
interest,  and  very  practical  use,  much  of  them  of 
none.  I  have  no  desire  to  add  to  the  host  of  abstruse 
and  abstract  discussions  of  metaphysical  points  in 
psychology,  already  far  too  numerous.  Were  I  an 
asylum  superintendent,  I  might  delight  the  Associa- 
tion by  a  discourse  upon  the  excellent  systems  by 
which  hospitals  are  now  heated  and  ventilated,  or 
the  question  as  to  whether,  as  regards  economy,  it  is 
better  for  superintendents  to  raise  or  to  purchase  their 
own  supplies  ;  upon  the  psychological  characteristics 
of  Milton,  Shakspeare,  Dante,  and  the  several  dra- 
matis personcc^  supernal,  mortal,  or  demoniac,  of 
these  and  other  writers  ;  upon  the  comparative  merits 
of  restraint  and  non-restraint,  and  as  to  where  the  lat- 
ter is  supposed  to  begin  and  to  end  ;  whether  Auba- 
nel  or  Brigham  invented  the  crib,  and  its  advantages 


IN   WOMEN.  15 

as  compared  with  the  bedstrap  of  Wyman,  and 
this  again  with  the  fingerless  gloves  of  Parkmann, 
the  handless  sleeves  and  muff  of  Haslam,  the  belts 
of  Reil,  and  of  the  York  Retreat,  the  manacles 
of  Ruer,  and  the  chains  of  time  immemorial,  the 
bifurcated  sack  of  Horn,  the  knee  breeches  of  Neu- 
mann, and  the  buckled  straps  of  Nostitz,  the  leathern 
mask  of  Autenrieth,  the  pear-shaped  frame  for  the 
mouth,  and  the  gag,  the  wicker  basket  of  Guislain, 
the  suspended  box  of  Hayner,  the  cord  and  the  re- 
straining chair,  the  dark  chamber  and  the  padded 
room,  the  rotary  machine  of  Darwin,  the  suspended 
seat  of  Cox,  the  hanging  mat  of  Hallaran,  the  hol- 
low wheel  of  Hayner,  the  swing  of  Chiarruggi,  the 
douche  and  the  surprise  bath,  the  proposal  of  our 
own  Rush,  whose  treatise  had  for  many  years  a  more 
extensive  circulation  among  American  physicians 
than  all  other  works  upon  mental  disorders  together, 
that  because  refractory  horses  are  subdued  by  being 
kept  from  lying  down  or  sleeping,  and  because  ele- 
phants, when  first  captured,  are  tamed  by  depriving 
them  of  food  until  they  discover  signs  of  great  ema- 
ciation, therefore  the  insane  should  be  kept  in  a 
standing  posture,  and  awake,  for  four  and  twenty 
hours,  and  fasting  for  several  days ! 

These  might  be  discussed,  and  other  methods 
of  subduing  violent  maniacs,  and  whether  a  little 
etherization  is  not,  after  all,  much   the  best ;  upon 


l6  REFLEX   INSANITY 

whether,  in  insanity,  the  mind  is  or  is  not  diseased, 
or  is  only  partially  hidden  by  a  transient  cloud  ;  upon 
the  pathological  results  of  insanity,  and  why  it  is  that 
in  every  affection  of  the  mind,  no  matter  how  diverse 
or  opposite,  we  may  find  identical  conditions  of  the 
brain,  or  no  trace  of  disease  whatever,  and  in  eveiy 
lesion  whatever  of  the  brain  we  may  find  an  entirely 
unaffected  mind ;  and  the  host  of  other  theoretical, 
practical,  and  transcendental  questions  so  fully  and 
so  ably  discussed  in  the  pages  of  the  American 
Journal  of  Insanity,  of  the  Asylum  Journal  of  Men- 
tal Science,  of  the  Journal  of  Psychological  Medi- 
cine, and  the  other  periodicals  devoted  to  the  inter- 
ests of  the  insane.  As  it  is,  having  been  chosen 
by  the  Association  to  this  work  in  consequence,  as 
I  suppose,  of  having  long  been  delving  in  the  spe- 
cial field  of  hysteria,  and  the  reflex  nervous  and 
neuralgic  demonstrations  of  invalid  women,  I  take  it 
for  granted  that  what  is  expected  at  my  hands  is,  to 
a  certain  extent,  of  a  special  character,  although  of 
necessity,  as  all  specialism  rests  upon  general  princi- 
ples, I  shall  endeavor  not  to  lose  sight  of  the  general 
basis  upon  which  it  lies. 

The  causation  and  the  cure  of  insanity  are  its 
Alpha  and  Onicga.  The  last  of  these  has  usually 
been  sought  the  first ;  and  it  is  because  the  other, 
upon  which  it  wholly  depends,  is  so  often  unsearched 
for  wisely,  if  at  all,  that  both  are  so  seldom  attained. 


IN   WOMEN.  17 

In  deciding,  therefore,  to  devote  the  major  part  of 
this  report  to  an  attempt  at  an  elucidation  of  the  true 
causation  of  mental  disturbance  in  a  large  proportion 
of  the  cases  in  which  it  obtains  in  women,  and  of  a 
more  rational  treatment  than  is  generally  adopted,  I 
took  early  occasion  to  consult  my  colleagues  upon  the 
committee,  who  were  all  of  them  superintendents, 
and,  without  a  single  exception,  of  public  and  State 
hospitals  for  the  insane.  They  were  Drs.  Bancroft, 
of  New  Hampshire ;  Van  Deusen,  of  Michigan ; 
Patterson,  of  Iowa ;  Woodburn,  of  Indiana ;  and 
Worthington,  of  the  Friends'  Asylum  at  Frankford, 
Pennsylvania. 

With  reference  to  the  opinions  of  these  gentlemen 
as  expressed  in  letters  from  which  I  shall  quote,  it  may 
be  stated  that  I  had  previously  avowed  it  as  my  be- 
lief that  very  many  cases  of  mental  disturbance  in 
women  are  of  reflex  character,  arising  from  pelvic 
irritation,  and  that  local  treatment  would  prove  of 
advantage  in  very  many  more  cases  than  those  for 
which  as  yet  it  had  ever  been  employed. 

Dr.  Bancroft  wrote  me  as  follows  :  — 

"  I  freely  admit  that  a  large  proportion  of  cases  of  insan- 
ity, even  in  both  sexes,  are  of  reflex  origin,  and  not  the  re- 
sult, primarily,  of  cerebral  change. 

"  I  am  well  aware,  also,  that  many  attacks  of  insanity  in 
females  originate  in  uterine  disturbance  of  some  sort,  and 
are  cured  bj  treatment  directed  to  that  organ. 

"  A  part  of  these  cases,  1  have  no  doubt,  require  topica 
treatment,  and,  of  course,  demand  examination  by  tact  and 

2 


l8  REFLEX    INSANITY 

the  speculum.  No  one  would  be  more  thankful  than  myselj 
for  better  facilities  than  are  at  present  afforded  for  investi- 
gating and  teaching  these  cases.* 

"  What  would  be  the  best  method  of  accomplishing  this 
object,  I  have  not  yet  a  settled  opinion. 

"  I  have  read  jour  published  articles  in  the  Boston  Med- 
ical and  Surgical  Journal;  f  and,  if  I  correctly  understand 
you,  you  hold  that  the  principal  cause  of  insanity  in  fe- 
males is  uterine  disorder  of  some  kind,  and  that  the  princi- 
pal treatment  in  females  is  therefore  to  be  directed  to  the 
uterus;  and  I  infer  further  from  your  writings  that  topical 
treatment  stands,  or  should  stand,  most  prominent. 

"  Although  admitting,  to  a  more  limited  extent,  the  truth 
of  3'our  positions,  yet  I  am  not  prepared  to  give  that  form 
of  disease  so  prominent  a  place  as  to  give  to  it  the  whole 
report,  to  the  exclusion  of  other  topics. 

"Although  your  idea  is  one  of  importance,  and  should 
receive  a  due  share  of  attention,  I  think  to  allow  it  to  absorb 
the  whole  report  would  but  partially  and  imperfectly  discuss 
the  great  points  of  interest  pertaining  to  insanity  in  this 
country." 

From  Dr.  Worthington  I  received  a  communica- 
tion of  similar  import. 

*'  I  believe  it  is  the  general  opinion  among  asylum  physi- 
cians," he  said,  "  that  insanity,  in  a  great  majority  of  cases, 
is  unattended  with  any  organic  cerebral  change;  and  the 
large  number  of  cases  of  the  disease  attributable  to  ill 
health,  in  the  reports  of  hospitals  for  the  insane,  is  evidence 
of  the  belief  of  their  authors  that  the  disease  is  very  com- 
monly consecutive  to  disorders  of  the  general  system. 
Among  these  disorders,  I  have  no  doubt  that  those  of  the 
genital  apparatus,  in  both  sexes,  are  productive  of  a  consid- 
erable number  of  cases  of  insanity.     I  can  call  to  mind  a 

•  The  Italics  above  are  my  own,  and  are  iised  because  of  the  importance  of 
ihe  admission  here  made,  in  reference  to  incidental  points  hereafter  to  be  con- 
sidered. 

♦  Loc.  cit.,  April  7,  October  13,  and  November  24,  1864. 


IN   WOMEN.  19 

case  where  a  simple  displacement  of  the  uterus  was  the 
cause  of  an  attack  of  insanity  of  two  years'  duration,  which 
was  remedied  in  this  institution,  in  a  short  time,  by  confin- 
ing the  patient  to  bed,  and  applying  a  suitable  pessary.  In 
all  cases  under  my  care,  where  there  is  reason  to  believe 
that  uterine  disease  may  be  the  cause  of  the  mental  disorder, 
I  have  always  been  in  the  habit  of  making  special  examina- 
tions, and  I  have  sometimes  called  in  the  assistance  of 
medical  friends  who  have  made  these  diseases  an  especial 
study. 

"On  the  other  hand,  I  have  gradually  become  convinced 
that  we  may  attach  too  much  importance  to  these  disorders 
as  a  cause  of  insanity,  and  that  in  our  willingness  to  refer 
the  mental  symptoms  to  irritation  reflected  from  the  uterus, 
we  may  overlook  the  more  serious  idiopathic  cerebral  dis- 
ease. I  have  known  the  latter  occur  coincident  with  uterine 
disorder,  and  yet  entirely  independent  of  it;  and  have  my- 
self lost  valuable  time  in  treating  the  uterine  aflfection,  and 
afterwards,  on  addressing  my  remedies  to  the  true  seat  of 
the  mental  disorder,  have  had  the  satisfaction  of  seeing  my 
patient  speedily  recover.  Such  cases  may  not  be  very  nu- 
merous, but  they  are  very  important  to  bear  in  mind,  and  I 
would  beg  leave  to  call  your  attention  specially  to  them.  It 
appears  to  me  to  be  particularly  desirable  to  discover  in  the 
character  of  the  mental  disorder  itself,  without  reference  to 
other  symptoms,  some  marks  by  which  we  may  be  able  to 
decide  whether  a  case  is  one  of  idiopathic  or  sympathetic 
cerebral  disorder." 

Dr.  Van  Deusen  confined  himself  to  the  discus- 
sion of  a  single  point  only,  and  that  merely  an  inci- 
dental one  as  compared  with  the  broad  subject  upon 
which  I  addressed  him,  and  concerning  which  we 
have  seen  Drs.  Bancroft  and  Worthington  so  fully  ex- 
pressing their  opinion.  The  matter  to  which  his  com- 
munication is  limited  is  that  upon  which  I  had  read 


20  REFLEX   INSANITY 

a  paper  at  the  previous  meeting  of  the  Association, 
which  will  be  found  published  in  the  volume  of  its 
Transactions  for  1864,  namely,  the  necessity,  for  the 
more  thorough  elucidation  of  each  case  of  insanity 
in  females,  that  consulting  physicians  should  be  ap- 
pointed to  every  hospital  for  the  insane.  To  Dr. 
Van  Deusen's  letter  I  shall  hereafter  refer. 
Dr.  Woodburn  wrote  me  as  follows  :  — 

"I  read  your  articles,  published  some  time  since  in  the 
Boston  Medical  and  Surgical  Journal,  and  was  well  pleased 
with  the  contents ;  but  would  venture  to  suggest  that  prob- 
ably insanity  is  not  so  frequently  caused  by  female  diseases 
as  the  papers  would  seem  to  indicate.  My  opinion  is,  that 
mental  derangement  is  always  caused,  either  by  physical 
disease  or  bodily  injury  (accidental  cases),  or  by  malforma- 
tion (hereditary  cases').  The  malformation  may  be  appar- 
ent, or  may  possibly  be  only  of  the  elementary  cells. 

"I  had  intended  to  write  a  short  paper,  which  you  might 
incorporate  with  your  report  if  you  thought  proper,  but  in 
the  press  of  other  duties  I  have  been  compelled  to  aban- 
don it." 

From  Dr,  Patterson  I  received  an  interesting  com- 
munication upon  the  general  causes  affecting  the 
mental  health,  more  particularly  of  women  in  country 
districts,  which  will  be  found  in  another  portion  of 
the  present  memoir. 

Willing  as  I  should  have  been  to  have  incorporated 
the  opinions  of  my  colleagues  to  a  greater  extent  in 
this  report,  whether  or  no  they  were  confirmatory  of 
my  own,  it  will  be  seen  that  I  am  compelled  in  great 
meastire  to  assume  its  sole  responsibility. 


IN   WOMEN.  21 


II.  —  Point  previously  attained. 

Reference  has  been  made  in  the  letters  of  these 
gentlemen  to  views  concerning  the  causation  of  in- 
sanity in  women  that  I  had  already  expressed.  These 
will  be  found  in  full,  or  in  abstract,  in  the  published 
proceedings  of  the  American  Academy  of  Arts  and 
Sciences  for  1864-5,  and  in  various  numbers  of  the 
Boston  Medical  and  Surgical  Journal  for  the  same 
period.  It  may  be  that  the  experience  of  others,  if 
carefully  analyzed,  will  not  wholly  confirm  me  in  the 
position  that  I  have  assumed ;  the  lapse  of  many 
months  (now  several  years),  however,  since  I  first 
threw  out  a  hint  of  my  convictions,  in  the  report  of 
the  Massachusetts  State  Commission  on  Insanity  for 
1863-4,  has  but  served  to  render  me  the  more  decided 
in  my  every  assumption,  and  I  believe  it  will  be  found, 
just  as  it  was  with  my  statements  concerning  the 
frequency  of  criminal  abortion, — a  report  upon  which, 
as  chairman  of  the  special  committee  upon  this  sub- 
ject, I  had  the  honor  to  render  to  the  American  Medi- 
cal Association  in  1859,*  —  that  though  my  premises 

*  To  my  colleagues  upon  that  committee,  Drs.  Blatchford,  of  New  York, 
Hodge,  of  Pennsylvania,  Pope,  of  Missouri,  Barton,  of  South  Carolina,  Lopez, 
of  Alabama,  Semmes,  of  the  District  of  Columbia,  and  Brisbane,  of  Wisconsiti, 
all  of  them  gentlemen  much  older  and  of  higher  standing  in  the  profession  than 
myself  (and  three  or  four  of  whom  have  now  deceased),  I  shall  always  feel  under 
deep  obligations  for  the  brave  and  sympathetic  alacrity  with  which  they  indorsed 
views  that  at  the  time  seemed  to  many,  of  an  earlier  school,  heretical  or  un. 
founded. 


33  REFLEX   INSANITY 

were  so  startling,  and  of  so  practical  results  as  to  be 
by  many  denied,  more  careful  and  more  general  in- 
vestigation has  shown  that  they  were  in  reality  very 
much  understated. 

Preliminarily,  I  wish  it  distinctly  understood,  — 

1 .  That  I  assert  for  the  insanity  of  women  neither 
a  universality  of  causation  or  of  treatment.  As  I 
have  already  been  misinterpreted  upon  both  these 
points  in  my  previous  writings,  clearly  as  I  en- 
deavored to  express  myself,  the  disclaimer  now  made 
is  not  unnecessary. 

2.  I  have  shown  that  in  the  writings  of  alienists, 
there  is  comparatiyely  very  little  to  be  found  in 
acknowledgment  of  the  part  played  by  her  sex  in  the 
causation  and  prolongation  of  insanity  in  women.  As 
regards  suggestion,  approbation,  or  demand  of  a  con- 
sequent and  rational  treatment,  even  less  than  this 
can  be  produced  from  the  authors  referred  to. 

I  do  not  state,  however,  that  the  key  to  insanity  in 
women  has  not  long  been  in  possession  of  these  gen- 
tlemen, but  I  prove  by  the  facts  adduced,  that  though 
they  may  have  possessed  it,  they  have  not  appreciated 
that  the  theory  referred  to  would  unlock,  what  has 
always  been  in  every  asylum,  as  in  every  psychologi- 
cal text-book,  a  sealed  question  and  an  opprobrium. 
They  have  not  used  it  for  this  purpose  in  their  annual 
reports,  in  their  memoirs,  in  their  published  statistics, 
or  in  their  medical  treatment. 


IN   WOMEN. 


23 


3.  I  have  alleged  that  in  a  very  large  proportion  of 
the  cases  of  insanity  occurring  in  woman,  her  sex  is 
in  reality  the  predisposing,  the  exciting,  or  the  con- 
tinuing cause  of  the  malady ;  but  I  do  not  assert  that 
there  are  never  present  other  predisposing,  exciting, 
or  continuing  causes  at  work  efficiently  in  women  as 
in  men. 

4.  I  have  claimed  that  from  the  above  premises  it 
follows  that  the  treatment  of  insane  women  should, 
in  many  instances,  be  of  a  direct  and  physical  charac- 
ter ;  but  this,  it  will  be  allowed,  is  a  very  different 
thing  from  teaching  that  the  treatment  of  insane  wo- 
men should  always  and  only  be  local ;  which  I  have 
never  advised,  and  which  I  should  myself  be  the  first 
to  condemn. 

5.  As  a  means,  and  only  as  a  means,  towards  the 
end  at  which  we  all  are  aiming,  namely,  the  cure  of 
the  patient,  I  have  endeavored  to  exhibit  the  necessity 
at  every  asylum  of  a  board  of  consulting  physicians, 
skilled  in  the  diagnosis  and  treatment  of  uterine  dis- 
ease, which  is  now  acknowledged  to  especially  require 
erudite  tact  and  an  appreciative  mind  ;  but  I  have 
distinctly  stated  that  such  aid  was  only  to  be  made 
use  of  at  the  discretion  of  the  superintendent,  whose 
monarchical  and  exclusive  sway,  legislative  and  ex- 
ecutive, economical  and  financial,  spiritual  and  cor- 
poreal, could  thus  in  nowise  be  lessened  or  interfered 
with. 


24  REFLEX   INSANITY 

If  superintendents  are  not  in  reality  afraid  of  a 
shadow,  if  they  are  not  disinclined  to  allow  the  pro- 
fession at  large  to  participate  in  the  study  of  mind 
diseased,  why  this  tone  of  suspicion,  or  jealousy,  or 
fear  that  a  simple,  needed,  and  practical  suggestion 
by  a  medical  man  who  knows  whereof  he  is  speaking, 
has  in  certain  quarters  called  forth  ? 

I  have  ventured  to  direct  the  attention  of  the  pro- 
fession to  the  results  then  and  now  again  to  be  placed 
before  them,  as  in  every  respect  important,  and  in 
some  respects  novel.  Their  right  to  this  last  attribute 
has  been  challenged,  and  in  a  quarter  where,  in  view 
of  all  the  circumstances,  we  should  have  last  looked 
for  any  counter  claim.  I  refer  to  a  statement  by 
the  editor-in-chief  of  the  official  organ  of  American 
Superintendents,  Dr.  John  P.  Gray,  of  the  Utica  Asy- 
lum.* Abundant  evidence  will  be  afforded  in  the 
present  paper  to  settle  all  doubt  upon  this  score. 

I  merely  wish  thus  beforehand  to  define  my  position  ; 
asserting  as  new  only  the  attempt  to  apply  upon  the 
large  scale  to  the  treatment  of  insane  women,  in 
asylums  as  in  private  practice,  views  that  in  theory 
were  partially  recognized  even  by  Hippocrates,  though 
they  have  been  practically  acted  upon  by  few  or  none 
of  his  successors. 

My  position  is  rather  that  of  the  pioneer  than  of 
the   discoverer.      There   is  little   positively   new   in 

•  MS.  Letter  of  December,  1864. 


IN    WOMEN.  25 

medicine  ;  there  is  much  that  is  comparatively  so. 
Not  a  statement,  however  original,  to  which  a  pre* 
vious  clew  has  not  existed  and  cannot  be  found.  Not 
a  psychologist,  however  practically  he  may  disbelieve 
in  a  local  origin  for  mental  derangement,  and  may 
have  put  his  disbelief  on  permanent  record,  but  might 
aver  that  such  origin  were  perfectly  familiar  to  him  ; 
that  he  learned  it  in  his  mother's  womb,  or  imbibed 
it  from  her  bosom,  even  that  he  inherited  its  knowl- 
edge from  his  ancestors,  for  cases  enough  were  on  rec- 
ord in  their  day  and  from  time  immemorial. 

I  have  referred  to  a  disposition  on  the  part  of  cer- 
tain individuals,  apparently  very  few  in  number,  to 
misinterpret  or  to  undervalue  facts  that  may  be  stated, 
or  deductions  that  may  be  draw^n,  by  any  one  who  is 
not  professedly  a  psychological  specialist,  and  upon 
that  ground.  I  shall  therefore  take  the  liberty  of 
fortifying  some  of  the  points  that  I  shall  make,  by  the 
evidence  or  the  language  of  gentlemen  whose  position 
within  the  inner  circle  alluded  to  is  such  as  to  render 
their  authority  unquestioned. 

For  instance  —  and  as  it  is  a  question  that  met  me 
upon  the  very  threshold  of  this  report,  I  have  little 
hesitation  in  presenting  it.  What  shall  be  allowed  to 
render  a  man  conversant  with  the  various  phases  of 
mental  disturbance?  One  superintendent,  the  phy- 
sician to  the  Utica  Asylum,  considers  that  it  can  only 
be  attained  by  prolonged  residence  In  an  insane  hos- 


26  REFLEX    INSANITY 

pital.  Under  date  of  January,  nth  ult.  (1865),  he 
writes  me  as  follows,  and  in  expressing  an  opinion  as 
to  views  of  my  own,  unless  it  was  arrived  at  very 
superficially  or  at  second  hand,  he  must  have  been 
aware  that  they  were  based  upon  no  isolated  case  or 
two,  but  upon  a  dozen  years  of  almost  exclusive 
observation,  upon  the  most  extended  scale,  of  sick 
women.     He  says, — 

"  It  certainly  appears  to  me  that  some  practical  experience 
in  the  management  and  treatment  of  the  insane,  acquired 
not  from  an  isolated  case  or  two,  but  in  some  large  hospital, 
would  greatly  modify  your  ideas.  You  would  then  have  an 
opportunity  of  ascertaining  what  is  really  known  on  the 
subject,  and  what  treatment  is  actually  practised  in  these 
institutions." 

On  the  other  hand,  it  is  possible  that  careful  com- 
parisons of  the  actual  working  detail  of  many  hos- 
pitals, of  the  plans,  medical  and  in  other  respects, 
under  which  they  are  conducted,  and  of  the  ideas  of 
their  respective  superintendents  as  afforded  Ijy  their 
various  systems  of  treatment,  seen  in  operation,  and 
described  personally  by  the  gentlen>en  themselves, 
may  perhaps  give  even  a  better  knowledge  of  what 
is  really  known  on  the  subject,  and  what  treatment  is 
actually  practised  in  these  institutions,  than  a  resi- 
dence, no  matter  for  what  length  of  time,  at  any 
asylum  in  the  land.  In  no  matter  is  the  old  saying 
of  Morgagni  more  true  than  in  this :  Perpendenda^ 
tion  numerandcB^  sunt  observationes. 


TN    WOMEN.  27 

Is  a  knowledge  of  psychological  literature  sufficient 
to  make  one  a  safe  guide?  There  is,  I  will  venture 
to  say,  no  department  of  medicine,  save  the  closely- 
allied  and  more  properly  considered  pseudo-science, 
phrenology,  whose  literature  is  so  crowded  with 
contradictory  statements  and  conflicting  theories,  with 
utterly  baseless  generalizations  and  facts  misinter- 
preted, as  this  department  of  insanity.  Each  suc- 
cessive text-book  has  repeated  the  errors,  or  many 
of  them,  of  its  predecessors.  There  are,  it  is  true, 
notable  exceptions,  the  various  works  of  Ray,  for  in- 
stance—  which  are  all  of  them,  for  originality  of 
thought,  for  closeness  of  obsen^ation,  and  for  justness 
of  reasoning,  veritable  oases  in  this  most  barren  of 
deserts ;  but  even  Bucknill  and  Tuke,  whose  book 
is  in  many  respects  one  of  the  best  of  modern  medi- 
cine, still  retain  the  old,  and  that  ought  to  be  obso- 
lete, artificial  classification  ;  which,  last  relic  of  an 
ancient  nosology,  would  separate  all  the  forms  of 
insanity  in  accordance  with  their  several  symptoms, 
and  by  ignoring  the  great  and  fundamental  question 
of  their  causation,  would  reduce  to  a  matter  of  unsafe 
and  blind  routine  their  chance  of  cure.  Each  author, 
moreover,  and  often  without  a  word  of  credit,  repeats 
the  details,  insufficient  or  irrelevant  though  they  may 
be,  of  cases  that  seem  to  have  been  handed  down 
from  time  almost  immemorial,  judging  from  the  dis- 


28  REFLEX   INSANITY 

tance  backward  to  which  in  several  instances  I  have 
traced  them. 

It  was  my  first  intention  to  have  presented  in  this 
report  a  summary  of  all  the  cases  on  record,  so  far  as 
I  could  collect  them,  illustrative  of  the  diagnosis,  pos- 
itive and  differential,  that  had  been  formed,  and  of  the 
treatment  of  insanity  in  women  by  past  and  present 
masters  in  psychological  medicine  ;  and  for  this  pur- 
pose I  had  tabulated  or  made  minutes  of  a  mass  of 
cases,  amounting  probably  to  several  hundreds ;  but, 
upon  more  carefully  examining  them,  they  were  found 
so  faulty,  or  so  imperfectly  reported,  as  for  all  prac- 
tical purposes  to  be  useless. 

What,  for  instance,  shall  I  say  of  the  fact,  that  while 
in  scores  and  in  hundreds  of  cases  great  care  has  been 
taken  to  say  whether  the  woman  had  or  had  not  had 
the  itch,  —  for  this  affection  was  formerly  considered 
an  important  agent  in  the  causation  of  insanity,  —  in 
scarcely  any,  on  the  other  hand,  however  plainly  con- 
nected with  pelvic  derangement,  is  any  physical 
examination  mentioned  or  its  results  given  ;  a  method 
of  studying  and  reporting  that  does  not  seem  to  have 
ceased  with  the  yeafs  bygone.  Or,  what  of  the  simi- 
lar fact  that,  in  the  autopsies  of  the  insane,  it  has  seldom 
seemed  necessary  to  critically  examine  other  organs 
of  the  body  than  the  brain,  even  though  that  showed 
no  trace  whatever  of  lesion.  Or  what,  again,  of  the 
other  fact,  still  almost  universal,  that   in  the   cases 


IN  WOMEN.  29 

of  undoubted  pelvic  origin  or  influence,  —  at  least,  in 
those  that  have  been  reported, — where  attempts  at 
physical  exploration  have  been  made,  precise  men- 
tion is  omitted  of  the  exact  species  of  local  disease 
that  was  ascertained  to  be  present,  so  important  in 
deciding  as  to  whether  the  means  resorted  to  for  its 
relief  were  exactly  what  were  required,  without 
which  correspondence  it  is  evident  a  cure  could  not 
be  hoped,  and  a  failure  to  effect  it  could  prove  no 
error  as  to  the  ultimate  causation  of  the  mental  dis- 
turbance. A  mind  that  has  been  trained  in  the  arena 
of  modern  general  practice,  and  is  accustomed  to  de- 
pend only  upon  the  most  rigid  and  rigorous  methods 
of  diagnosis,  finds  little  in  such  faulty  material  that 
either  satisfies  or  is  edifying. 

Let  me  give,  upon  this  point,  a  single  forcible  word 
from  one  of  the  best  psychological  authorities  in  this 
country,  Dr.  Workman,  of  Toronto,  the  superintend- 
ent of  the  immense  government  asylum  of  Canada 
West.     He  writes  me  as  follows  :  — 

"  So  much  has  been  written  on  insanity,  as  I  am  sure  you 
know,  the  tendency  of  which  has  only  been  to  becloud  the 
subject,  that  even  when  one  is  fortunate  enough  to  command 
a  good  proportion  of  the  works,  he  has  to  wade  through  ter- 
rible cesspool  accumulations,  or  scramble  over  piles  of  for- 
saken habitations,  before  he  dare  venture  to  say  to  the  world 
that  he  has  begun  to  study." 

With  this  word  of  explanation,  which  will  have 
been  seen  to  be  necessary,  I  proceed. 


30  REFLEX  INSANITY 


III.  —  Work  to  be  done. 

I  had  intended  to  have  presented  in  this  report  a 
carefully  prepared  and  somewhat  complete  essay 
upon  the  insanity  of  women,  it  being  my  opinion,  as 
stated  in  my  paper  published  in  the  volume  of  tlie 
Transactions  of  the  Association  for  1865,  — 

I.  That  in  women  mental  disease  is  often,  perhaps 
generally,  dependent  upon  functional  or  organic  dis- 
turbance of  the  reproductive  system. 

II.  That  in  women  the  access  or  exacerbation  of 
mental  disease  is  usually  coincident  with  the  catame- 
nial  establishment,  its  periodical  access,  temporary 
suppression,  or  final  cessation.     And,  therefore,  — 

III.  That  the  rational  and  successful  treatment  of 
mental  disease  in  women  must  be  based  upon  the 
preceding  theories,  which  I  have  claimed  are  estab- 
lished, — 

1.  By  many  analogies,  physiological  and  pathologi- 
cal, in  the  cerebral  manifestations  of  the  human  fe- 
male and  that  of  the  lower  mammals. 

2.  By  clinical  observation  ;  and,  — 

3.  By  the  results  of  autopsies  of  the  insane,  both  in 
private  practice  and,  where  made  with  equal  care  and 
impartiality,  in  insane  asylums. 

To  cover,  however,  properly  all  the  ground  that  I 
had  marked  out  would  occupy  a  larger  space  than, 


IN  WOMEN.  31 

perhaps,  one  has  a  right  to  claim  for  a  single  report ; 
and  since  it  was  commenced,  I  have  received  com- 
munications, published  and  private,  of  such  a  charac- 
ter as  have  satisfied  me  that  it  is  better  at  this  time 
and  in  this  place  to  strike  boldly  at  the  very  root  of 
the  present  S3'stem  of  theory  and  management  of  in- 
sanity in  women,  before  attempting  to  train  a  health- 
ier and  sturdier  growth  in  its  stead.  Convinced 
of  being  correct  in  this,  I  intend,  health  permitting, 
to  pursue  it ;  and,  to  prove  that  I  am  in  earnest,  now 
subjoin  a  sketch  of  the  essay  that  I  have  already  par- 
tially prepared  for  submitting  to  the  Association. 

I.  Causation. 

The  insanity  of  woman  proved  generally  peripheral  and 
reflex  — 

1.  By  evidence  negative. 

a.  Admissions  of  psychologists. 

a.  Cerebral  disease  without  insanity. 
/?.  Insanity  without  cerebral  disease. 

b.  Omission  of  autopsies. 

c.  Neglect  at  autopsies. 

d.  Results  of  autopsies. 

a.  At  asylums. 

/J.  At  general  hospitals. 

y.  In  civil  practice. 

2.  By  evidence  positive. 

a.  Analogies  from  — 

a.  Other  sympathetic  results. 
I.  On  nerves  sensory. 
II.  On  nerves  motor. 
III.  On  functions  organic. 
*  IV.  On  functions  animal. 
V.  On  fcetus  in  utero. 
p.  Madness  in  lower  mammals. 


3^  REFLEX   INSANITY 

y.  Admissions  — 

I.  Of  psychologists. 
II.  Of  gynaecologists. 
III.  Of  women  themselves. 
d.  Cases  on  record. 
I.  Psychical. 
II.  Obstetrical. 
t.  Cases  now  first  given. 
C.  Autopsies  — 

I.  On  record. 
II.  Now  first  given. 
1/.  Time  of  development. 
I.  Fcjetal. 
II.  Congenital. 

III.  Puberal. 

IV.  Catamenial. 
V.  Nuptal. 

VI.  Gestal. 
VII.  Puerperal. 
VIII.  Lacteal. 
IX.  Climaxal. 
X.  Senile. 

XI.  Organic  disease. 
6.  Effect  of  treatment  — 
I.  At  asylums. 
II.  In  civil  practice. 
».  Reflex  induction  of  cerebral  derangement. 
X.  Reflex  cure  of  cerebral  derangement. 
X.  Not  necessary  to  expect  uterine  disease  al- 
ways to  produce  insanity,  even  if  it  were 
allowed   that   insanity    in   women   were 
usually  induced  by  uterine  disease. 
II.  Theory  of  ultimate  causation. 
I.  Effect  on  general  health  — 
a.  Of  pain. 
d.  Of  abnormal  flux. 
a.  Hemorrhagic. 
|J.  Leucorrhoeal. 
y.  Lacteal. 


IN   WOMEN.  33 

a.  Cerebral  irritation. 

a.  Direct. 

b.  Reflex. 

3.  Circulation  of  carbon,  uneliminated 

a.  Bv  lungs. 

b.  By  uterus. 

o.  In  virginitj. 
/?.  In  pregnancy. 
I.  Healthy. 
11.  Diseased. 

4.  Dystocia. 

5.  Uterine  inheritance. 

a.  Metritic. 
/?.  Placental. 

6.  Toxsemia. 

III.  Indications  of  Prevention. 

IV.  Indications  of  Rational  Treatment. 

1.  To  ascertain  the  primary  lesion. 

2.  To  prevent  exacerbating  influences. 

3.  To  relieve  physical  symptoms. 

4.  To  remove  the  exciting  cause,  it  being  of  no  slight 
moment  — 

a.  At  what  stage  a  patient  is  treated. 

b.  And  in  vv^hat  way  she  is  treated,  whether 

a.  According  to  the  individual  case,  or 
/S.  By  routine. 

It  will  be  perceived  that  there  is  much  that  can  be 
said  that  I  believe  has  not  been  said  upon  this  most 
interesting  and  practical  topic,  just  as  there  is  much 
that  can  be  done  that  has  not  yet  been  done  towards 
relieving  or  curing  its  unfortunate  victims.  I  have 
now  at  hand  a  large  mass  of  material,  original  and 
collected,  concerning  the  various  points  above  indi- 
cated, that  I  shall  hope  to  present  to  the  profession  at 
some  future  period. 


34  REFLEX   INSANITY 

In  the  mean  time  I  shall  endeavor  to  take  by  the 
horns  one  or  two  little  chimeras  that  have  been 
shaken  at  me,  or  at  any  rate  to  look  them  in  the 
face. 

It  has  been  asserted,  in  communications  addressed  to 
me  since  I  have  been  appointed  upon  this  committee. 
or  in  publications  intended  to  break  down,  to  discred- 
it, or  to  ridicule  my  testimony,  — 

1.  That  insanity  in  women  is  seldom  dependent 
upon  a  pelvic  cause. 

2.  That  it  has  so  frequently  been  recognized  as  thus 
dependent,  that  any  discussion  of  the  subject  is  unne- 
cessary. 

3.  That  thorough  physical  examinations  of  insane 
women  are  already  generally  made  whenever  required. 

4.  That  such  are  not  required. 

5.  That  they  would  be  positively  injurious  to  the 
patient  herself,  and,  if  in  an  asylum,  to  the  other 
patients,  and  to  general  discipline. 

It  will  be  hardly  possible  for  me  to  give  to  each  of 
these  contradictory  points  the  attention  their  impor- 
tance deserves,  although  I  am  prepared,  in  each  in- 
stance, to  show  their  utter  worthlessness. 

In  what,  however,  I  shall  say,  I  shall  endea^'or,  so 
far  as  possible,  to  take  my  arguments  from  psycholo- 
gists themselves,  using,  in  the  main,  their  own  words, 
originally  written  though  these  may  have  been  for  a 
different  purpose,  and  in  ignorance  of  the  real  char- 


IN   WOMEN.  35 

acter  and  meaning  of  the  facts  described.  Were 
these  gentlemen  aware  of  the  inconsistencies,  both  in 
theory  and  practice,  that  are  everywhere  recorded  in 
their  special  literature,  they  would  be  much  more 
careful  than  one  or  two  of  them  have  lately  been  ;  for 
it  is  evident,  — 

1.  That  if  my  views  are  true,  but  yet  long  known, 
then  local  examination  and  treatment  ought  not  to 
have  been  stated  to  be  generally  unnecessary  or  posi- 
tively injurious ;  and,  — 

2.  That,  if  they  are  false,  then  it  cannot  be  claimed 
that  they  have  long  been  recognized  as  well  founded, 
and,  in  practice,  daily  carried  out  to  the  letter,  both  of 
which  conflicting  assertions  have  been  made  by  gentle 
men  claiming  to  be  leaders  in  the  specialty  of  insanity. 

Due  allowances  are,  of  course,  to  be  made  for  a 
certain  measure  of  professional  conservatism,  how- 
ever arrogantly  expressed ;  and  I  do  not  entirely  in- 
dorse, though  I  quote,  the  following  remarks  by  Dr. 
Gait,  of  Virginia,  himself  a  superintendent,  and  then 
of  the  Eastern  Asylum.  They  are  none  the  less  per- 
tinent, however,  as  coming  from  that  source,  and  as 
made  to  rebuke  the  tendency  of  an  older  school  to 
repress  innovation,  or  even  inquiry. 

*'  The  laudator  temporis  acti  is  so  common,  that  we  do  not 
think  it  necessary  to  quote  the  opinions  of  the  past  on  the 
present  subject.  As  a  general  rute,  wricers  allow  a  change 
to  be  effected,  if,  as  they  say,  it  is  feasible.     But  such  a  mode 


36  REFLEX    INSANITY 

of  argument  is  no  longer  admissible.  He  who  opposes  the 
proposed  arrangement,  must  be  prepared  to  defend  himself 
on  the  assertion  of  its  intrinsic  inferiority.  Admitting, 
however,  such  fancies  to  stand  for  what  they  are  worth,  we 
still  find  the  medical  world  divided  as  to  the  matter  in  ques- 
tion ;  and  this  circumstance  itself  should  induce  us  to  lean 
to  the  new  views,  because  every  one  is  aware  of  the  preju- 
dices which  association  weaves  about  established  customs 
and  regulations.  It  is  said  that  when  Harvey  declared  to 
the  world  his  discovery  of  the  circulation  of  the  blood,  no 
physician  beyond  forty  years  of  age  gave  in  his  adhesion  to 
the  new  views."  ♦ 

IV.  —  The  Brain  the  Seat  of  Insanity,  not 

ALWAYS   OF    its   CaUSE. 

I  have  dared  to  say,  that,  in  my  opinion,  the  an- 
cient and  still  usual  classification  of  insanity,  which 
artificially  divides  the  forms  of  mental  aberration 
according  to  their  mental  peculiarities,  is  faulty  and 
erroneous.  Such  a  method  of  classifying  disease 
according  to  its  symptoms  alone,  would  not,  at  the 
present  day,  be  tolerated  in  any  other  department  of 
medicine.  It  is  the  more  necessary  to  dwell  for  a 
few  moments  upon  the  question  here  involved,  for  it 
lies  at  the  foundation  of  this  report ;  and  upon  its 
decision  depends,  in  great  measure,  the  truth  of  my 
views  concerning  the  insanity  of  women,  novel  or 
trite  as  these  may  prove. 

Dr.  Workman,  of  Toronto,  to  whom  I  have  already 
alluded,  seems  to  have  argued  more  boldly  and  more 

*  American  Journal  of  Insanity,  xi.  23> 


IN   WOMEN.  37 

ably  for  the  extra-cerebral  causation  of  insanity  than, 
perhaps,  any  other  writer  in  this  country,  both  in  his 
own  writings  and  his  late  translation  of  Schroeder 
van  der  Kolk's  little  work  upon  the  pathology  and 
theraupeutics  of  insanity,  in  the  American  Superin- 
tendents' Journal.*     He  writes  me  as  follows  :  — 

"  What  can  be  more  exact,  what  more  rational,  what  more 
practically  suitable  than  the  assignment  of  all  cases  of  in- 
sanity to  the  two  grand  heads,  idiopathic  and  sympathetic? 
in  other  words,  fixing  all  insanity  either  in  the  brain  or  otit 
of  it.  It  has  long  been  my  belief  that,  unless  in  confirmed 
low  dementia  and  idiocy,  insanity  has  no  necessary  connec- 
tion with  diseased  brain,  properly  so  called.  I  believe  that 
when  appreciable,  palpable  disease  exists  in  the  brain,  we 
always  have  something  ^f's/t/^.v,  and  something  e.wg»//<7//y  dif- 
ferent from  insanity.  It  does  not  satisfy  me  to  be  told  that 
disease  in  the  brain  may  exist  and  be  undetectable.  We  do 
not  admit  this  assertion  in  application  to  any  other  organ  or 
structure.  If  you  ask  me  to  admit  the  presence  of  disease 
in  the  eye,  or  the  ear,  or  the  lungs,  and  fail,  by  scalpel  or 
microscope  to  demonstrate  it,  am  I  sceptic  because  I  refuse 
credence.? 

"  The  circular  argument  of  starting  with  the  premises, 
that,  as  the  brain  is  the  organ  of  the  mind,  and  insanity  is 
a  disease  of  the  mind,  therefore  the  brain,  in  insanity,  must 
be  diseased,  whether  we  detect  the  disease  or  not,  has,  it 
appears  to  me,  been  too  long  deferred  to.  The  fallacy  here 
may  exist  in  any  one,  or  in  all,  the  terms  of  the  syllogism. 

'' I.  I  would  say  I  do  not  comprehend  the  term  'organ 
of  the  mind.'  I  understand  the  terms  organ  of  sight,  organ 
of  taste,  organ  of  digestion,  of  circulation,  of  urination, 
&c.,  &c. ;  but  where  is  the  parallelism,  or  even  the  resem- 
blance, between  these  functions  and  thought.-* 

"2.  What  is  meant  by  disease  of  mind?     What  is  the 

*  American  Joiimal  of  Insanity,  April  and  July,  1864,  p.  63,  &c 


5S  REFLBX   INSANITY 

parallelism,  or  even  remote  resemblance,  between  any  form 
of  bodily  disease  and  mental  abnormality? 

"3.  Why  should  a  diseased  brain  be  essential  to  insanity? 
If  it  is  absent  in  a  single  case,  its  presence  cannot  be  essen- 
tial. I  believe  it  is  absent  in  many  cases,  yea,  in  the  major- 
ity of  cases.  Have  you  carefully  noted  the  mental  condition 
of  persons  dying  under  pulmonary  consumption  ?  and,  if  so, 
have  you  not  often  been  struck  with  its  close  approximation 
to  insanity?  Pulmonary  disease  is  present  in  a  very  large 
proportion  of  cases  of  insanity,  and  I  believe  in  incurable 
cases  it  is  present  in  fully  one  half.  We  may,  or  we  may 
not,  discover  cerebral  lesion  5«/<?r-added  —  very  generally  I 
think  not.    This  fact  is  surely  one  of  much  significance. 

"  In  all  emotional  insanity  of  women,  and  especially  in 
the  religious  forms,  I  am  persuaded  the  generative  organs 
play  a  most  important  part.  I  would  almost  say,  they  give 
the  ground-tone." 

I  shall  now  proceed  to  show,  — 

1.  That  while  the  brain  is  undoubtedly  the  seat  of 
insanity,  yet  it  is  not  necessarily  the  seat  of  its  cause. 

2.  And  that  this  is  proved  by  a  priori  reasoning, 
and,  both  negatively  and  positively,  by  the  results  of 
autopsies. 

3.  That  while  idiopathic  insanity,  requiring  direct 
cerebral  or  simply  moral  treatment  alone,  is  very  rare, 
sympathetic  or  reflex  insanity,  requiring  treatment  of 
a  special  character,  is  extremely  common. 

4.  And  that,  on  the  one  hand,  such  reflex  causation 
is  and  should  be  much  more  common  in  females  than 
in  males,  while,  on  the  otlier  hand,  of  tlie  various 
forms  of  it  occurring  in  females,  the  majority  of  them 
are  owing  to  functional  or  organic  diseases  of  the 


IN   WOMEN.  39 

uterus  and  its  appendages  ;  in  other  words,  that  they 
are  of  a  sexual  character. 

These  facts  I  shall  support  at  this  time  only  by  the 
evidence  of  superintendents  themselves,  by  no  means 
exhausting  the  testimony  of  this  character  that  I  have 
at  hand,  nor  drawing  upon  the  extensive  material  that 
is  afforded  me  from  other  quarters,  which  I  shall  re- 
serve for  a  future  communication  upon  the  subject, 
that  may  hereafter  be  made  by  me  to  the  profession. 

The  first  witness  whom  I  call  is  Dr.  Ray,  of  the 
Butler  Hospital,  at  Providence,  R.  I.  (now,  1870,  of 
Philadelphia). 

"It  can  hardly  be  necessary,  at  the  present  time,"  says 
this  gentleman,  "  to  prove  the  fact  of  the  dependence  of  the 
mind  on  the  brain  for  its  external  manifestations;  that,  in 
short,  the  brain  is  the  material  organ  of  the  intellectual  and 
effective  powers.  Whatever  opinion  may  be  entertained  of 
the  nature  of  the  mind,  it  is  generally  admitted,  at  least  by 
all  enlightened  physiologists,  that  it  must  of  necessity  be 
put  in  connection  with  matter,  and  that  the  brain  is  the  part 
of  the  body  by  means  of  which  this  connection  is  effected. 
Little  as  we  know  beyond  this  single  fact,  it  is  enough  to 
•warrant  the  inference  that  derangement  of  the  structure,  or 
of  the  vital  actions,  of  the  brain,  must  be  followed  by  abnor- 
mal manifestations  of  the  mind,  and,  consequently,  that  the 
presence  of  the  effect  indicates  the  existence  of  the  cause. 
"Whether  the  morbid  action  arises  in  the  digestive  or  some 
other  system,  and  is  reflected  thence  to  the  brain  by  means 
of  the  nervous  sympathies,  or  arises  primarily  in  the  brain, 
the  soundness  of  the  above  principle  is  equally  untouched. 
This  leads  us  to  the  source  of  the  hesitation  that  has  been 
evinced  by  pathologists  to  consider  the  brain  as  the  seat  of 
insanity. 


4©  REFLEX    INSANITY 

"  From  the  fact  that  organic  lesions  are  not  always  dis- 
coverable after  death  in  the  brains  of  the  subjects  of  insan- 
ity, it  has  been  inferred  that  the  brain  is  not  the  seatof  tkis 
disease;  though,  if  this  fact  were  true,  —  it  being  also  true 
that  no  other  organ  in  the  body  invariably  presents  marks 
of  organic  derangement  in  insanity,  —  the  only  legitimate 
inference  would  have  been,  that,  in  some  cases,  it  is  impos- 
sible to  discover  such  lesions  by  any  means  in  our  power. 
The  strangest  theoretical  error  which  this  soundness  of  the 
brain  in  some  cases  has  occasioned,  is  that  of  denying  the 
existence  of  any  material  affection  at  all,  and  attributing  the 
disease  entirely  to  an  affection  of  the  immaterial  principle. 
If  the  same  pathological  principles  had  guided  men's  rea- 
soning, respecting  this  disease,  that  they  have  applied  to  the 
investigation  of  others,  this  error  would  never  have  been 
committed.  It  will  scarcely  be  contended,  at  the  present 
day,  at  least,  that  the  structural  changes  found  after  death, 
from  any  disease,  are  the  primary  cause  of  the  disturbances 
manifested  by  symptoms  during  life,  or  that,  if  the  interior 
could  be  inspected  at  the  beginning  of  the  disease,  any  of 
these  structural  changes  would  be  discovered.  It  is  now  a 
well-recognized  principle  that  such  changes  must  be  pre- 
ceded by  some  change  in  the  vital  actions  of  the  part  where 
they  occur.  This  vital  change  is  now  generally  expressed 
by  the  term  irritation^  and  nothing  is  implied  by  it  relative 
to  the  nature  of  this  change  more  than  an  exaltation  of  ac- 
tion. Irritation,  then,  is  the  initial  stage  of  disease  —  the 
first  in  the  chain  of  events,  of  which  disorganization  is  the 
last;  and,  of  course,  nothing  can  be  more  unphilosophical 
than  to  attribute  disturbances  of  function  exclusively  to  any 
structural  changes  that  may  take  place  during  the  progress 
of  these  successive  stages."  ♦ 

To  what  pathological  actions  or  structural  changes 
is  the  brain  then  liable?  And  here  I  present  the 
evidence  of  Dr.  Bucknill,  of  England,  medical  super* 

*  Medical  Jurisprudence  of  Insanity,  pp.  laS-ija 


IN  WOMEN.  41 

intendent  of  the  Devon  County  Lunatic  Asylum.    He 

tells  us,  — 

'*  As  an  organ  abundantly  supplied  with  blood  vessels,  the 
brain  is  obviously  liable  to  all  abnormal  conditions,  which 
irregularities  in  the  quality  or  quantity  of  the  blood,  and  the 
relation  thereof  to  its  tissue,  can  occasion ;  it  is  liable  to 
anaemia  and  to  hyperaemia,  both  passive  and  active,  and  to 
the  latter  accompanied  by  organizable  and  unorganizable 
exudates.  It  is  also  more  readily  acted  upon  by  various 
chemical  changes  in  the  blood  than  any  other  organ.  Ex- 
cess of  carbon  or  defect  of  oxygen  tells  first  upon  it;  and 
many  substances  in  the  blood  which  affect  other  organs  little, 
or  not  at  all,  affect  this  noblest  of  the  organs  with  intense 
force.  All  diseases,  therefore,  which  depend  upon  the  move- 
ment or  quantity  of  the  blood,  and  many  of  those  which 
depend  upon  its  quality,  are  the  fruitful  source  of  abnormal 
cerebral  conditions.  There  are,  it  is  true,  many  blood- 
poisons  and  diseases  which  do  not  affect  the  brain.  Thus, 
it  is  strange,  that  although  the  gout-poison  affects  the  tem- 
per strongly,  and  often  endangers  the  intellect,  that  of 
rheumatism  has  no  effect  thereon.  Tuberculosis,  moreover, 
while  attacking  every  other  organ  of  the  body,  very  rarely 
affects  the  adult  cerebrum.  But  the  brain  is  liable  to  a 
species  of  disturbance,  apparently  quite  unconnected  with 
the  quality,  quantity,  or  movement  of  the  blood,  a  species 
of  disturbance  to  which  other  organs  are  liable  only  in  a 
modified  and  unimportant  degree.  We  allude  to  the  dis- 
turbance caused  by  sympathy  with  injuries  of,  or  noxious 
influences  applied  to,  peripheral  portions  of  the  nervous 
system.* 

These  sympathetic  disturbances,  however,  occa- 
sioned by  the  irritation  of  some  part  of  the  distal 
nervous  system,  do  not  necessarily  produce  any  ana- 
tomical changes,  if  the  examination  is  made  during 

*  Manual  of  Psychological  Mediclue,  p.  349. 


^2  REFLEX  INSANITY 

the  early  period  of  the  disease.*  After  a  while,  the 
brain  may  pass  from  the  state  of  physiological  excite- 
ment into  that  of  pathological  change,  and  altera- 
tions in  its  structure  then  be  found  on  examination, 
although  this  is  by  no  means  necessarily  the  case. 

"  The  condition  of  the  cerebral  substance  is  the  prime 
question  in  the  pathology  of  mental  disease.  Frequently 
this  condition  can  only  be  judged  of  by  the  state  of  its  blood 
vessels,  or  can  only  be  guessed  at  by  that  of  its  membranes, 
or  some  still  more  remote  indication.  Not  unfrequently,  in 
partial  and  sympathetic  insanity,  it  appears  to  be  perfectly 
sound  in  structure,  although  the  deductions  of  science  assure 
us  that  this  soundness  is  in  appearance  only,  and  is  solely 
attributable  to  the  imperfection  of  our  means  of  observing 
and  investigating. 

"  To  the  pathologist  the  substance  of  the  brain  is  as  yet 
practically  structureless.  Although  the  microscope  reveals 
cells  and  tubes,  and  intervening  stroma,  up  to  the  present 
time  it  is  unable  to  indicate  when  they  are  in  a  normal  or 
abnormal  state ;  and  although  it  may  prove  that  in  so»ne 
cases  the  smaller  arteries  are  diseased,  that  in  a  few  others 
there  are  exudation-corpuscles,  or  an  increase  of  fatty  parti- 
cles in  the  substance  itself,  it  has  not  yet  enabled  us  to 
distinguish  between  the  states  of  the  whole  organ,  which 
must  be  diametrically  opposite  —  for  instance,  between  the 
state  of  hypertrophy  and  atrophj'."! 

Let  us  again  listen  to  Dr.  Ray. 

"  It  has  been  stated  by  Fodere,  in  explanation  of  the 
pathological  causes  that  produce  the  alternation  of  parox- 
ysms and  lucid  intervals  so  constantly  seen  in  certain  fom.a 
of  insanity,  that  the  former  are  attended  by  an  excessive 
plethora  of  the  blood  vessels  of  the  brain,  and  the  latter  by  a 
relaxed,  atonic  condition  of  these  vessels,  which  is  an  effect 

•  Manual  of  Psychologica]  Medicine,  p.  403. 
t  Tbid.,  p.  431. 


IN   WOMEN.  43 

of  their  previous  forcible  distention.  In  this  condition  the^ 
are  liable  to  be  suddenly  engorged  hy  exciting  causes,  such 
as  intemperance  in  eating  or  drinking,  anger,  violent  exer- 
cise, insolation,  &c. ;  or  in  consequence  of  a  certain  predis- 
position of  constitution.  It  is,  indeed,  well  known  that  the 
return  of  the  paroxysms  is  often  retarded  bv  regulated  diet, 
bleeding,  quiet,  seclusion,  kind  treatment,  and  the  absence 
of  the  above  named  stimuli.  It  is  thus  shown  conclusively 
that  in  every  lucid  interval  there  remains  some  unsoundness 
of  the  material  organ  of  the  mind,  which  may  be  designated 
generallj-  as  a  morbid  irritability,  which,  on  the  application 
of  the  slightest  exciting  cause,  may  produce  an  outbreak  of 
mania  in  all  its  original  severity."  • 

"  But,"  asks  Andral,  in  his  Clinique  Medicale, 
"  when  we  have  referred  the  symptoms  to  hyperaemia 
in  one  case,  and  to  anaemia  in  another,  are  we  to  come 
to  the  bottom  of  the  subject.''  By  no  means,"  he  re- 
plies to  his  own  question ;  for  this  hyperaemia  and 
this  anaemia  are  themselves  mere  effects,  which  —  a 
thing  very  remarkable  —  the  same  influence  can  very 
often  produce. 

In  Esquirol's  great  work  upon  maladies  of  the 
mind,  published  so  recently  as  1838,  his  opinions  on 
pathology,  which  had  been  in  accordance  with  those 
still  so  generally  held  concerning  the  insane,  will  be 
found  to  have  been  considerably  modified.  Referring 
to  the  case  of  a  recent  maniac,  who  was  killed  by  one 
of  her  companions,  and  in  whose  body  he  and  his 
pupils  were  surprised  to  find  no  lesions  of  the  brain 
or  its  meninges,  he  declares  that  pathological  anato* 

•  Medical  Jurisprudence  of  Insajiity,  p.  339. 


44  REFLEX    INSANITY 

my,  in  spite  of  the  very  important  labors  of  Foville, 

Calmeil,  Bayle,  Guislain,  and  others,  has  not  been 

able  to  make  us  acquainted  with  the  organic  cause 

of  mania.     He  says,  — 

"Thirty  years  ago  I  would  willingly  have  written  upon 
the  pathological  cause  of  madness.  At  the  present  day  I 
would  not  attempt  a  labor  so  difficult,  so  much  of  incertitude 
and  contradiction  is  there  in  the  results  of  the  necroscopy  of 
the  insane  made  up  to  this  time.  But  I  may  add  that  mod- 
ern researches  permit  us  to  hope  for  ideas  more  positive, 
more  clear,  and  more  satisfactory." 

We  are  now  naturally  conducted  to  the  actual  re- 
sults of  post-mortem  examinations  of  the  insane.  I 
again  quote  Esquirol :  — 

*•  From  this  announcement,  every  one  might  expect  that 
we  should  be  able  to  point  out  the  seat  of  insanity,  and  to 
make  known  the  nature  and  seat  of  the  organic  lesion,  of 
which  insanity  is  the  expression.  This  we  can  by  no  means 
accomplish.  The  examinations  of  the  dead  have,  to  the 
present  period,  been  barren  of  practical  information.  The 
facts  observed  by  Willis,  Manget,  Bonnet,  Morgagni.  Gunz, 
Meckel,  Greding,  Vicq  d'Azyr,  Camper,  Chaussier,  Gall, 
and  others,  have  produced  only  negative  or  contradictory 
results. 

"  All  the  labor  that  has  been  expended  upon  the  anatomy 
of  the  brain  has  produced  no  other  result  than  a  more  exact 
description  of  this  organ,  and  the  despairing  certainty  of  our 
being  forever  unable  to  assign  to  its  parts  the  uses  from 
whence  we  ma}-  derive  information  with  reference  to  the 
exercise  of  the  thinking  faculty,  whether  in  health  or 
disease. 

"  Before  drawing  any  conclusions,"  continues  this  great 
authority,  "from  these  organic  lesions  observed  among  the 
insane,  will  it  not  be  well  to  acquaint  ourselves  with  all  the 
varieties,  both  of  the  cranium  and  of  the  brain,  which  are 


IN    WOMEN.  45 

compatible  with  the  integrity  of  the  faculties  of  the  under- 
standing? Would  not  this  be  the  true  point  of  departure  fot 
all  our  pathological  researches?  Now,  says  the  learned 
Chaussier,  there  is  no  organ  in  which  we  find  greater  vari- 
eties, with  respect  to  volume,  weight,  density,  and  its  re- 
spective proportions,  than  the  brain.  Have  we  carefully 
distinguished  the  results  of  concomitant  maladies,  or  those 
diseases  which  terminate  the  life  of  the  insane,  from  those 
which  belong  to  mental  alienation? 

"  Organic  lesions  of  the  brain  reveal  themselves  by  other 
signs  than  insanity.  Thus,  chronic  inflammation  of  the 
meninges  produces  compression,  which  reveals  itself  by 
paralysis;  cerebral  hemorrhage  is  also  manifested  by  paral- 
ysis. Tubercle,  cancer,  and  softening  of  the  brain  pre- 
sent peculiar  characters,  which  cannot  be  confounded  with 
mental  alienation.  Have  we  reflected  on  the  sudden  and 
instantaneous  cures  of  insanity?  It  is  in  consequence  of 
having  neglected  these  considerations  that  we  reason  so 
erroneously  respecting  the  seat  of  this  malady."  * 

Let  us  see  what  light  upon  these  points  has  been 
aflbrded  by  actual  study  of  the  dead. 

Autopsies  are  comparatively  seldom  made  of  the 
insane  who  die  at  asylums.  The  reason,  or  one  rea- 
son, of  this  will  have  been  already  made  evident  — 
examination  of  the  brain,  so  barren  of  result,  having 
usually  alone  been  made.  Upon  this  point  I  will 
reproduce  evidence  that  I  have  already  elsewhere 
presented.! 

"  Many  who  have  professed  familiarity  with  these  sub- 
jects have  asserted  that  the  morbid  appearances  found  in 
the  bodies  of  the  insane  were  unworthy  of  record ;  they 
should   rather   have    confessed   that   they  were   unable   to 

*  Mental  Maladies,  p.  69. 

t  Boston  Med.  and  Surg.  Journal,  April,  1864,  p.  198. 


46  REFLEX    INSANITY 

appreciate  their  value.  With  the  more  thorough  and  com* 
plete  investigation  of  these  matters,  we  may  hope  eventually 
to  arrive  at  some  correct  views  as  to  the  nature  of  those  laws, 
the  transgression  of  which  leads  to  sensorial  disturbance,  but 
no  approach  to  the  truth  can  be  made  except  through  the 
portal  of  morbid  anatomy,  which  has  revealed  this  important 
fact,  that  the  record  of  post-mortem  examinations,  as  pre- 
served in  an  asylum  for  the  insane,  differs  in  most  striking 
and  essential  particulars  from  that  preserved  in  a  general 
public  hospital."  * 

"  Autopsies,"  said  Dr.  Douglass  to  me,  when  visit- 
ing the  Government  Asylum  of  Lower  Canada  at 
Beaufort,  near  Quebec,  then  under  his  charge,  "  au- 
topsies of  the  insane  no  one  ever  thinks  of  making  in 
Canada,  save  that  enthusiast  whom  you  have  been 
visiting  at  Toronto."  While,  on  the  other  hand,  it  is 
from  this  very  enthusiast  at  Toronto,  Dr.  Workman, 
to  whom  I  have  already  alluded,  that  the  profession 
is  indebted  for  some  of  the  most  important  of  the 
steps  towards  elucidating  the  real  pathology  and  ulti- 
mate causation  of  insanity  in  its  reflex  manifestations, 
that  have  ever  yet  been  made. 

Dr.  Hunt,  formerly  of  the  Hartford  Asylum,  has 

put  the  following  admission  on  record  :  — 

"  The  number  of  post-mortem  examinations  made  m  the 
hospitals  for  the  treatment  of  insanity  in  this  country  is  very 
few,  and  of  this  number  fewer  still  are  ever  published. 
The  cause  is  evident,  and  is  not  likely  very  soon  to  be  ob- 
viated." t 

•  Holmes  Coote :  Journal  of  Psychological  Medicine,  vol.  iv.  p.  384. 

t  I  freely  acknowledge  that  in  some  instances,  as  was  stated  by  Drs  Choata 
and  Bemis  at  the  meeting  of  Superintendents  held  at  Providence  (Am.  Jour, 
of  Insanity,  July,  tS6a),  it  is  di£Bcult  or  impossible  to  obtain  the  consent  of 


IN    WOMEN.  47 

The  examination,  which  was  permitted  me,  of  the 
very  extended,  minute,  and  most  suggestive  patho- 
logical records  at  Toronto,  furnished  proof  that  this 
paucity  of  autopsies  is  owing  neither  to  "  want  of 
opportunity,"  *  nor  to  dearth  of  practical  results,  when 
properly  looked  for. 

It  is  proved,  however,  from  abundant  evidence,  that, 

1.  Insanity  may  exist  without  structural  changes 
of  the  brain,  and  that, 

2.  Structural  changes  of  the  brain  may  exist  with- 
out insanity. 

"  It  must  be  admitted,"  says  Dr.  Bucknill,  "  that 
we  are  not  yet  in  a  position,  as  regards  our  knowl- 
edge of  the  morbid  appearances  of  the  brain,  to  base 
our  nosology  upon  the  revelations  of  the  dead-houses. 
We  can  only  wait  an  advance  of  knowledge  which 
will  render  this  possible."  f 

The  late  Dr.  Bell,  of  the  McLean  Asylum,  at  Som- 
erville,  justly  considered  one  of  our  most  reliable 
authorities,  has  left  no  doubtful  expression  of  his  own 
opinion,  which  was,  that  autopsies  of  the  insane 
generally  present  no  material  lesion  of  the  brain ; 
changes,  indeed,  there  are  to  be  seen,  but  only  those 
that  may  have  occurred  in  articulo  mortis.J 

a  patient's  friends  to  have  a  post-mortem  examination  ;  but  this  difficulty 
obtains  to  neariy  an  equal  degree  at  general  hospitals,  where,  nevertheless,  such 
examinations  are  much  more  conunon. 

*  Translation  of  Esquirol,  p.  233. 

t  X.OC.  citat.,  p.  94. 

t  American  Journal  of  Insanity,  x.  p.  79, 


48  REFLEX    INSANITY 

Upon  another  occasion  he  stated  that  my  friend, 
the  hite  Dr.  Waldo  I.  Burnett,  of  Boston,  one  of  the 
most  accomplished  microscopists  in  the  country,  had 
made  examinations  of  the  brain  of  persons  who  had 
died  in  a  state  of  chronic  insanity,  but  had  been  un- 
able to  discover  any  change  of  structure  whatever,  or 
any  sign  to  indicate  that  it  did  not  belong  to  an  indi- 
vidual whose  mind  was  unaffected.* 

Dr.  Bucknill  observes,  — 

"  The  brains  of  the  insane  appear  to  be  certainly  not  more 
liable  than  those  of  others  to  various  incidental  affections. 
Thus,  in  four  hundred  autopsies  of  the  insane,  we  have  only 
once  met  with  a  hydatid,  only  once  with  tubercular  deposit 
in  the  substance  and  meninges,  only  once  with  a  fibro-cel- 
lular  tumor,  and  not  once  with  malignant  disease.  The 
arteries  at  the  base  do  not  appear  to  be  more  frequently  or 
extensively  affected  with  atheromatous  change  than  those 
of  sane  persons  of  the  same  age ;  and  in  the  bodies  of  the 
insane  we  have  never  yet  met  with  that  cretaceous  deposit 
in  the  coats  of  the  small  arteries,  which  makes  them  feel  like 
pieces  of  fine  wire  imbedded  in  the  brain-substance.  We 
have  never  met  with  that  leather-like  and  fibro-cartilaginous 
hardness  or  resistance  to  which  sclerosis  of  the  brain  is  de- 
scribed to  attain.  The  two  forms  of  ramollissement  are  not 
found  more  frequently  in  the  brains  of  persons  dying  insane 
than  in  those  of  others.  The  same  may  be  said  of  the  cellular 
infiltration  described  by  Durand  Fardel,  with  which  in  four 
hundred  autopsies  we  have  met  but  twice. 

"A  large  number  of  brains  of  the  insane  we  have  dili- 
gently investigated  with  a  first-rate  microscope.  The  results 
appear  to  us  to  have  afforded  no  distinction  between  the  sane 
and  the  insane  brain.  We  have  found  exudation  corpuscles, 
but  only  in  instances  where  the  existence  of  inflammatory 

•  Aincricin  Journal  of  Insanity,  xi.  1854,  p.  53. 


IN    WOMEN.  49 

action  was  apparent  without  the  use  of  the  microscope;  and, 
therefore,  this  microscopic  test  of  cerebral  inflammation, 
proposed  bj  Dr.  Hughes  Bennett,  appears  to  be  of  little  val- 
ue. In  inflammatory  and  softened  parts  of  the  brain-sub- 
stance we  have  found  fatty  degeneration  of  the  coats  of  the 
small  arteries;  but  it  remains  to  be  seen  whether  this  change 
is  not  as  frequent  in  the  brains  of  the  sane.  We  have  not 
been  able  to  discover  fatty  degeneration  of  the  arteries  where 
the  pathological  changes  more  peculiar  to  insanity  alone 
existed.  The  same  may  be  said  of  fatty  degeneration  of  the 
brain-substance,  consisting  in  the  abundant  dissemination 
of  amorphous  fat  particles,  which  is  found  in  some  speci- 
mens of  cerebral  softening. 

"  It  seemed  reasonable  to  expect  that,  by  the  aid  of  the 
microscope,  one  would  be  able  to  ascertain  whether  any  ex- 
udation or  addition  to  the  stroma  of  the  brain,  or  any  change 
in  size,  shape,  or  proportionate  number  of  its  cells,  takes 
place;  and  in  the  indurated  brain  of  chronic  insanity, 
whether  that  finely  fibrillated  exudate,  which  has  been  de- 
scribed by  some  writers,  actually  exists ;  also,  whether,  in 
extreme  atrophy  of  the  brain,  any  proportion  exists  in  the 
diminution  or  degeneration  in  the  form  of  the  cells  or  tubes. 
In  none  of  these  points  of  inquiry  have  we  been  able  to 
attain  the  slightest  success."  * 

It  could  hardly  b'e  expected,  when  the  contents  of 

the   cranial    cavity    throw   so    little    light   upon   the 

pathological  character  of  insanity,  that  a  study  of  its 

exterior  could  be  productive  of  fruitful  results.    Such, 

however,   has   been   assiduously  attempted,  but   the 

results  are  neither  uniform  nor  undoubted. 

*'  Although  we  believe  "  —  it  is  Bucknill  who  is  now  speak- 
ing—  "that  the  average  dimensions  of  the  head  are  below 
those  of  the  sane,  when  the  comparison  is  obtained  by  the 
examination  of  large  numbers,  still,  in  a  great  number  of 

•  Loc  citat.,  p.  430. 


5©  REFLEX    INSANITY 

instances,  they  will  be  found  to  be  good:  and.  indeed.  th« 
head  is  frequently  not  only  large,  but  phrenologically  well- 
shaped. 

*'  We  are  not  aware  in  what  proportion  of  the  ^ane  the 
shape  of  the  head  is  peculiar,  since  it  is  rare  that  opportuni- 
ties occur  for  making  the  observation  among  them  ;  but 
among  the  insane  a  considerable  proportion  present  decided 
peculiarities  in  the  shape  of  the  cranium.  The  most  fre- 
quent one  is  a  want  of  symmetry  in  the  two  sides.  One 
side  is  rather  flatter  or  smaller  than  the  other,  or  the  whole 
cranium  is  pushed  over  a  little  to  one  side,  or  one  side  is  a 
little  more  forward  than  the  other,  or  the  two  anomalies  co- 
exist, giving  the  cranium  a  sort  of  twisted  appearance. 
These  things  will  not  be  seen  unless  they  are  looked  for, 
with  accurate  and  careful  eyes,  upon  the  shaven  scalp. 

"Sometimes  the  skull  is  high  and  domelike;  more  fre- 
quently it  is  as  if  it  had  been  compressed  laterally,  and 
elongated  from  before  backwards  —  heel-shaped,  in  fact, 
like  the  skulls  figured  by  Dr.  Minchin,*  in  which  the  centres 
of  ossification  of  the  parietal  bones  are  increased  in  num- 
ber. Sometimes  the  forehead  is  preternaturally  flat,  nar- 
row, or  receding,  or  very  large  and  bulging,  or  the  occipital 
region  is  deficient,  and  the  back  of  the  head  rises  in  a 
straight  line  with  the  nape  of  the  neck.  Sometimes  the 
skull  has  a  remarkably  square  configuration.  The  square 
and  carinated  form  of  skull  we  have  most  frequently  seen  in 
connection  with  mania;  the  domelike  and  high,  vertical 
skull,  and  also  the  unsymmetrical  skull,  most  frequently  in 
melancholia.  In  mania  the  anterior  cranium  is  more  fre- 
quently of  good  shape  and  size  than  in  melancholia.  In 
the  latter  the  forehead  is  often  small  and  mean,  but  some- 
times it  is  disproportionately  large  and  globose.  The  shape 
of  the  head,  indicated  by  the  rules  of  phrenologists,  can 
only  fairly  be  expected  to  coincide  with  the  mental  symp- 
toms in  those  somewhat  rare  instances  in  which  insanity  is 
the  mere  development  in  excess  of  natural  character;  and 
in  some  such  instances  we  have  found  the  shape  of  the  head 

•  Dublin  Medical  Journal. 


IN    WOMEN.  51 

tally,  in  its  general  outline,  with  the  indications  of  phre* 
nology. 

"  Occasionally  depressions  are  found  in  the  outer  skull, 
which  sometimes  do,  and  sometimes  do  not,  correspond 
with  the  bulging  of  the  inner  table  of  the  cranium.  When 
they  do  not  correspond,  we  have  found  that  they  indicate  a 
local  absorbtion  of  the  diploe. 

"It  is  an  interesting  question  how  far  the  shape  of  the 
skull  alters  in  insanity.  If  the  forehead  expands,  even  in 
mature  age,  under  the  influence  of  intellectual  development, 
it  is  likely  that  it  will  contract  under  the  influence  of  intel- 
lectual decay.  Some  writers  have  asserted  that  the  shrink- 
ing of  the  brain  in  atrophy  is  commonly,  and  to  a  consider- 
able extent  followed,  and  the  cranium  filled,  by  a  flattening 
and  shrinking  of  the  cranial  bones.*  Rokitansky  also  af- 
firms that  atrophy  of  the  brain  frequently  gives  rise  to  de- 
posit of  bone  on  the  inner  table  of  the  skull,  especially 
about  the  anterior  convolutions. 

"We  have  not  satisfied  ourselves  that  the  increased  thick- 
ness of  the  cranium,  which  is  frequently  met  with  in  the  in- 
sane, is  in  any  way  connected  with  atrophy  of  the  brain. 
Some  of  the  thickest  and  heaviest  craniums  which  we  have 
met  with  have  occurred  in  instances  in  which  there  was 
little  or  no  cerebral  atrophy ;  and  the  condition  of  the  cra- 
nium, where  there  is  undoubted  atrophy  of  the  brain,  is  not 
unfrequently  one  of  abnormal  tenuity."  f 

Thus  it  is  seen  not  merely  that  there  is  no  direct 
correspondence  between  the  exterior  of  the  skull  and 
mental  integrity,  any  more  than  between  the  exterior 
of  the  skull  and  the  shape  and  consistence  of  its  con- 
tents. We  constantly  see  all  the  degrees  of  irregu- 
larity and  excess  or  deficiency  of  cranial  development 
that  have  been  described,  in  every-day  life,  and  coin- 

*  Paget :  Lectures  on  Pathology, 
t  Loc  citat,  p.  41CX 


5a  RHFLEX    IXSANITY 

cident  with  perfect  sanity,  while  even  in  idiocy  it  ia 
not  necessary  that  the  normal  symmetry  shall  at  all 
be  lacking,  though  this  is  undoubtedly  frequently  the 
case. 

It  must  not  be  concluded,  from  the  examples  of 
microcephalous  idiots,  that  a  small  head  is  a  necessa- 
ry accompaniment  of  idiocy.  "  On  the  contrary," 
says  Dr.  Tuke,  Medical  Officer  to  the  York  Retreat, 
"  many  idiots  have  large  heads,  leaving  out  of  the 
question  instances  of  hydrocephalus."  Parchappe 
has  stated,  as  the  result  of  very  careful  inquiry,  that 
if  there  exist  a  general  relation  between  the  volume 
of  the  brain  and  the  degree  of  intelligence,  "  facts 
are  wanting  to  deduce  rigorously,  from  this  relation, 
the  different  degrees  of  intellectual  and  moral  capaci- 
ty." Of  one  hundred  idiotic  heads  examined  by 
Belhomme,  eighty-four  presented  more  or  less  decid- 
ed malformations  of  the  forehead,  occiput,  and  lateral 
portions.  Twenty-five  per  cent,  had  a  well-marked 
want  of  symmetry.  On  bringing  together  a  hundred 
well-proportioned  heads,  he  did  not  find  a  single  idiot 
among  the  number.  Gallice,  after  making  a  large 
number  of  observations,  came  to  the  conclusion,  that 
the  more  intelligent  the  idiot  is,  the  larger  will  be  his 
head  ;  but  that  this  results  from  a  greater  develop- 
ment of  the  occiput.  And  this  certainly  accords  with 
what  Leuret  had  previously  recorded,  that  the  occi- 
put in  idiots  is  remarkably  small. 


IN    WOMEN.  53 

Desmaisons,  in  his  Memoir  on  the  Form  of  the 
Head  in  Idiots,  concludes  that  idiocy  sometimes  exists 
without  any  malformation  ;  that  it  is  impossible  to  fix 
upon  any  malformation  peculiar  to  idiocy,  when  the 
volume  of  the  head  and  its  symmetry  are  retained ; 
and  that,  in  cases  of  this  kind,  flattening  of  the  pos- 
terior portion  of  the  head  is  as  common  as  that  of 
the  forehead.*  Gall  laid  it  down  as  an  axiom,  that 
idiocy  must  exist  when  the  head  is  not  more  than 
thirteen  inches  in  circumference ;  and  he  says  that 
the  measurement  of  heads,  in  cases  of  complete  im- 
becility, up  to  the  ordinary  exercise  of  the  intellectual 
faculties,  is  comprehended  between  the  following  lim- 
its :  The  circumference  varies  from  fourteen  to  seven- 
teen inches,  and  the  arc,  between  the  root  of  the  nose 
and  the  occipital  foramen,  measures  nearly  twelve. 
These  dimensions,  he  adds,  are  accompanied  with  a 
greater  or  less  degree  of  stupidity  or  fatuity,  inability 
(more  or  less  complete)  of  fixing  the  attention  on  a 
determinate  object,  vague  sentiments,  an  irregular 
train  of  ideas,  speech  consisting  of  broken  phrases, 
&c.,  and  blind  and  irregular  instincts.f 

Esquirol's  statements  appear  to  be  somewhat  con- 
tradictory ;  for  while  a  table  of  measurements,  which 
he  gives,  exhibits  a  decided  decrease  in  the  size  of  the 
heads  of  idiots,  he  says,    "  The   dimensions  of  the 

•  Manual  of  Psychological  Medicine,  p.  108. 
t  The  Functions  of  the  Brain,  ii.  p.  214. 


54  REFLEX   INSANITY 

crania  of  idiots  are  equal  to  those  of  other  men,** 
and  concludes  by  exclaiming,  "  How  much  work 
there  remains  to  accomplish,  how  much  research, 
before  we  can  state  the  coincidence  of  the  volume 
and  form  of  the  head  with  the  intellectual  capacity !  " 
From  the  author  last  quoted  I  present  the  following 
conclusions :  — 

1.  Vices  of  conformation  in  the  cranium  are  met 
with  only,  or  chiefly,  among  imbeciles,  idiots,  and 
cretins. 

2.  Organic  lesions  of  the  encephalon  and  its  en- 
velopes have  been  observed  only  among  those  whose 
insanity  was  complicated  with  paralysis,  convulsions, 
and  epilepsy,  or  rather  these  lesions  appertain  to  the 
malady  which  has  caused  the  death  of  the  patients. 

3.  The  sanguineous  or  serous  effusions,  the  injec- 
tions or  infiltrations,  which  we  meet  with  in  the  cra- 
nial cavity,  the  thickening  of  the  meninges,  their  ad- 
hesions among  themselves,  with  the  cranium  and  the 
gray  substance,  the  partial  or  general  softening  of  the 
brain,  the  density  of  this  organ,  the  fibrous,  knotty, 
and  cancerous  tumors  observed  within  the  cranium. 
—  all  these  alterations  indicate  either  the  causes  or 
effects  of  insanity,  or  rather  the  effects  of  a  compli- 
cation to  which  the  patients  have  yielded. 

4.  The  alterations  within  the  thorax,  abdomen,  and 
pelvic  cavity  are  evidently  independent  of  insanity. 
These    alterations    may,   nevertheless,   indicate    the 


IN  WOMEN.  55 

source  of  mental  alienation,  by  showing  the  organ 
primitively  affected,  which  has  reacted  upon  the 
brain. 

5.  All  the  organic  lesions  obsei"ved  among  the  in- 
sane are  found  to  exist  among  those  who  have  never 
suffered  from  chronic  delirium. 

6.  Many  post-mortem  examinations  of  the  insane 
have  revealed  no  alteration,  although  the  insanity 
may  have  persisted  for  a  great  number  of  years. 

7.  Pathological  anatomy  shows  us  every  part  of 
the  encephalon  altered,  in  a  state  of  suppuration,  and 
destroyed,  without  chronic  lesion  of  the  understanding. 

8.  From  the  above  data  we  may  conclude  that  there 
are  cases  of  insanity  whose  immediate  cause  escapes 
our  means  of  investigation  ;  that  insanity  depends 
upon  an  unknown  modification  of  the  brain ;  that  it 
has  not  always  its  point  of  departure  in  the  brain, 
but  rather  in  the  foci  of  sensibility,  situated  in  differ- 
ent regions  of  the  body,  as  disorders  of  the  circula- 
tion do  not  always  depend  upon  lesions  of  the  heart, 
but  upon  those  of  some  other  portion  of  the  vascular 
system.* 

Lelut,  who  has  also  closely  investigated  this  sub- 
ject, sums  up  the  result  of  his  researches  in  the  fol- 
lowing words :  — 

"  I.  Numerous  alterations  of  the  brain  and  its  envelopes 
are  met  with  in  delirium  and  insanity,  especially  in  extreme 

*  Mental  Maladies,  p.  7a 


56  REFLEX    INSANITY 

forms  of  the  latter;  but  these  alterations  are  neither  con« 
stant  nor  exclusive. 

"2.  Hence  it  mustbe  allowed  that  the  more  or  less  local  and 
coarse  alterations  in  the  skull,  the  brain,  and  its  membranes, 
cannot  be  held  to  be  the  proximate  causes  of  insanity.  They 
are,  doubtless,  capable  of  existing  with  a  delirious  or  insane 
condition;  but  they  do  not  constitute  this  condition,  and 
frequently  they  are  only  the  exaggeration,  the  effect,  or  the 
transl<jimation  of  it. 

"3.  That  which  may  be  given  as  the  nearest  approach  to 
the  proximate  cause  of  delirium,  and  to  the  most  acute  form 
of  insanity,  is  inflammatory  lesion  of  the  brain  and  its  tu- 
nics. But  this  alteration  neither  does  nor  can  constitute  the 
state  which  is  anterior  to  it,  and  may  even  destroy  life  with- 
out producing  lu 

"  4.  The  conditions  of  the  brain  which  approach  the  most 
closely  to  the  proximate  cause  of  the  chronic  forms  of  men- 
tal alienation,  with  or  without  impairment  of  motion,  are 
without  doubt  chronic  inflammation  of  the  substance  and 
of  the  membranes  of  the  brain,  its  atrophy  and  induration, 
which  may  be  accompanied  by  variations  in  its  specific 
gravity.  But  yet  these  alterations  are  not  the  proximate 
cause  of  these  forms  of  insanity,  because  they  are  neither 
constant  nor  exclusive,  and  they  do  not  make  themselves 
apparent  except  in  an  advanced  period  of  the  disease."  * 

These  generalizations  are  carried  to  a  still  further 
extent  by  another  writer  upon  the  subject  (Leuret), 
who  states,  — 

I.  That  the  authors  who  believe  it  possible  to  es- 
tablish an  anatomical  chano^e  as  the  cause  of  insanity 
diflbr  greatly  among  themselves.  Thus  Greding  as- 
serted that  thickness  of  tlie  bones  of  the  cranium 
occurs  in  seventy-seven  out  of  one  hundred  patients, 

*  Essay  on  the  Value  of  Cerebral  Alterations  in  Acute  Delirium  and  Insanity. 


IN    WOMEN.  57 

while  Haslam  found  this  condition  in  ten  only  out  of 
one  hundred  patients.  Hyperasmia  of  the  brain  is 
recorded  by  Parchappe  in  forty-three  cases  out  of  one 
hundred,  and  by  Bertoleni  only  in  fourteen  out  of  one 
hundred. 

2.  That  some  of  the  cerebral  alterations  to  which 
insanity  is  attributed  are  by  no  means  well  established. 
Thus,  in  the  cases  which  are  cited  of  hypertrophy  of 
the  brain,  it  ought  to  have  been  shown  that  this  was 
not  owing  to  fulness  of  its  vessels,  or  to  the  presence 
of  a  serosity  in  its  tissue.  These  observations  have 
not  been  made.  Again,  that  which  is  called  dense 
brain,  or  a  soft  brain,  expresses  nothing  distinctly, 
except  in  extreme  cases. 

3.  That  the  value  attributed  to  certain  alterations  is 
deduced  from  a  number  of  observations  by  far  too 
small,  so  that  one  result  frequently  invalidates  anoth- 
er. Thus  Parchappe  has  deduced  the  average  normal 
weight  of  the  healthy  brain  from  thirteen  observa- 
tions upon  men,  and  nine  upon  women,  and  on  this 
average  he  establishes  the  rule  for  atrophy  of  the 
brain.  This  average  is  evidently  too  small,  and,  in- 
deed, Parchappe  himself  gives  different  averages  else- 
where. 

4.  That  the  pathological  alterations  referred  to  in- 
sanity are  met  with  in  patients  who  have  never  been 
insane. 

5.  That  all  authors  confess  that  there  are  insane 


58  REFLEX    INSANITY 

persons  in  whose  brains  no  pathological  changes  are 
found. 

6.  That  the  lesions  which  are  frequently  met  with 
among  the  insane,  to  which  any  value  can  be  at- 
tached, are  only  met  with  in  cases  in  which  insanity 
has  been  complicated  with  paralysis ;  and  that,  in 
order  to  decide  if  any  lesion  is  the  cause  of  insanity, 
it  is  at  least  necessary  to  find  it  in  a  case  of  simple 
mental  aberration,  in  which  there  has  been  no  affec- 
tion of  motion  or  sensibility.* 

The  only  answer  that  has  been  made,  or  that  can 
be  made,  to  these  arguments,  namely,  that  more  mi- 
nute methods  of  examination  may  perhaps  be  discov- 
ered which  may  show  what  the  most  powerful  micro- 
scope as  yet  does  not,  is  very  unsatisfactory ;  the 
more  so  in  view  of  the  fact  that  the  supposition  of 
reflex  causation  is  sufficient  to  account  for  every  mys- 
tery, as  it  is  allowed  to  do  in  neuralgia,  tetanus,  cho- 
rea, and  hysteria.  Dr.  Bucknill  is  here  at  fault,  and, 
like  every  other  writer  who  falls  back  upon  the  brain 
as  tlie  seat  of  causation  in  insanity,  proves  inconsist- 
ent with  himself.f  It  is  possible  that  Brown-Sequard 
and  John  Dean,  of  Boston,  may  yet  localize  more 
disturbance  in  the  brain,  as  they  have  so  much  in  the 
spinal  cord  ;  but  they  cannot  all. 

What   conclusion,   then,  with  Esquirol,  shall  we 

*  The  Moral  Treatment  of  Insanity, 
t  Loc  cit.,  pp.  398-400. 


IN   WOMEN.  59 

draw  from  the  facts  that  have  now  been  presented  ? 
That  the  changes  observed  in  the  brain  and  its  mem- 
branes are  found  in  subjects  who  have  given  no  indi- 
cation of  delirium  ;  that  organic  lesions  of  the  en- 
cephalon  appertain  to  paralysis  and  convulsions  rather 
than  to  dementia  ;  and  that  the  character  and  intensity 
of  the  delirium  are  not  in  proportion  to  the  extent  of 
the  organic  lesion.  What  shall  we  conclude  ?  That 
the  examinations  of  the  bodies  of  the  dead,  which 
have  so  often  furnished  important  information  respect- 
ing the  seat  of  disease,  present  no  result  which  is  sat- 
isfactory respecting  the  source  and  immediate  cause 
of  insanity.  If  in  dementia  there  are  indications  of 
compression,  sinking  and  collapse  of  the  encephalon, 
is  this  state  caused  by  the  engorgement  of  the  vascu- 
lar system,  or  by  the  lessening  of  the  cerebral  circu- 
lation? Do  not  the  arteries,  having  lost  their  elasti- 
city or  being  ossified,  propel  with  sufficient  energy  the 
blood  which  flows  languidly  in  veins  already  too 
greatly  dilated?  Does  not  the  inflammation  of  the 
meninges,  by  thickening  the  membranes,  or  by  pro- 
voking a  too  abundant  serous  exhalation,  induce  the 
compression .''  Does  not  the  contracting  of  the  cranial 
cavity,  by  the  separation  of  the  internal  table,  partic- 
ularly of  the  cranial  portion,  contribute  to  compress 
the  brain  ?  Post-mortem  examinations  teach  us  little 
in   this   respect ;  all   the   organic   alterations   of  the 


60  REFLEX    INSANITY 

brain  or  its  dependencies  appertaining  less  to  the 
delirium  than  to  its  complications.* 

Dr.  Nichols,  of  Washington,  Superintendent  of  the 
Government  Hospital  for  the  Insane,  has  expressed 
his  opinion  upon  this  subject  in  no  uncertain  lan- 
guage, "  believing  it  highly  important  both  to  science 
and  humanity.  Therapeutists  and  pathologists,"  we 
are  told,  "  are  approaching,  from  different  starting- 
points,  a  like  rational,  and  what  is  much  the  most 
important,  the  true  theoy  of  the  proximate  cause  of 
insanity,  upon  which  better  defined  and  more  rational 
principles  of  a  more  successful  treatment  of  the  dis- 
ease will  be  based." 

Recent  English  writers  upon  this  subject  have 
taken  a  middle  ground  between  certain  German  au- 
thors, who  believe  in  a  disorder  of  the  mental  entity 
itself,  and  that  much  larger  class  who  have  vainly  ex- 
pected to  connect  special  forms  of  mental  aberration 
with  pathognomonic  changes  of  cerebral  structure, 
and  tell  us  that  "  microscopical  appearances  ought  to 
be  regarded  more  as  the  effect  than  the  source  of  the 
malady  "  (Hitchman  )  ;  that  "  insanity  is  a  disease 
of  nervous  origin  "  (Munro)  ;  and  that  it  is  "  a  neu- 
ralgia of  the  sensory  fibres  of  the  brain  "  (Dewey). 

"And  I  venture  to  predict,"  says  Dr.  Nichols,  "that  we 
are  on  the  eve  of  the  demonstrable  discovery,  that  all  insan- 
ity, whether  of  physical  or  moral  semeiology,  is  proxiniate- 

*  Mental  Maladies,  p.  433. 


IN    WOMEN,  6l 

]y  owing  to  a  derangement  of  the  functional  activity  of 
the  cerebral  organ  as  a  generator  of  what  we  are  accustomed 
to  call  nerve  power,  nervous  fluid,  &c. 

"  That  function  may  be  exalted  or  depressed,  through  the 
whole  or  a  part  of  the  brain,  as  we  have  general  mental  ex- 
citement or  general  depression,  or  one  or  more  of  the  infi- 
nite variety  of  intervening  shades  and  forms  of  aberration. 
This  purely  functional  derangement  may,  and  probably  not 
unfrequently  does,  run  into  inflammation,  but  they  have  no 
necessary  connection,  and  the  more  furious  mania  ttiay,  in 
my  opinion,  exist  without  any  more  inflammatory  origin  or 
organic  change  than  obtains  in  a  fit  of  jumping'  tooth- 
ache, which  occurs  in  a  moment  and  goes  in  the  next,  with- 
out leaving  any  trace  of  its  existence.''  * 

VVe  are  thus  compelled,  at  times,  to  seek  the  ulti- 
mate causation  of  insanity  outside  the  brain. 

"The  special  student  of  insanity,"  says  Bucknill,  "will 
do  well  to  study  the  causes  of  delirious  thought  and  per- 
verted feeling,  in  all  classes  of  bodily  disorder  where  they 
are  observable.  If  he  studies  insanity  alone,  he  will  be  apt 
to  fall  into  the  common  error  of  attributing  its  causation  to 
some  single  pathological  state,  and  his  views  will  be  as 
wrong  as  they  are  narrow.  But,  if  he  studies  perverted  feel- 
ing as  occasioned  b}'  gouty  or  hepatic  disease  or  loss  of  in- 
tellectual power,  and  fatal  coma  occasioned  by  suppression 
of  the  urine,  and  the  delirium  of  fevers,  he  will  be  led  to 
appreciate  the  full  extent  of  blood-change  in  the  produc- 
tion of  purely  mental  affections.  In  the  delirium  of  cere- 
britis,  he  will  see  a  form  of  insanity  undoubtedly  produced 
by  inflammation;  and  in  delirium  tremens,  he  will  see  an- 
other form  of  insanity,  as  undoubtedly  produced  by  nervous 
exhaustion.  He  will  thus  be  enabled  to  reject  exclusive  the- 
ories of  insanity,  and  be  prepared  to  admit  the  [truth]  of 
the  broad  principle,  that  insanity  may  be  occasioned  by  any 
and   every   pathological   state   which  is   capable   of  taking 

•  Amer.  Journ.  of  Insanity,  xi.  s^- 


63  REFLEX    INSANITY 

place  within  the  substance  of  the  brain,  however  ultimately 
occasioned."* 

The  various  evidences  that  I  have  now  adduced 
should  tend  to  convince  that,  as  I  have  nowhere  found 
expressed  so  clearly  as  by  Morel,  the  brain  is  al- 
ways THE  SEAT  OF  INSANITY,  BUT  IT  IS  NOT  ALWAYS 
THE  SEAT  OF  ITS  CAUSE,  t 

V.  —  Explanations  of  Distant  Causation. 

Whence  else,  then,  can  insanity  arise  than  in  the 
brain  ? 

It  has  been  supposed  by  some  that  it  is  generally 
the  effect  of  toxaemia.  This  is  undoubtedly  at  times 
the  cause,  and  probably  much  more  often  than  has 
been  generally  supposed.  Besides  the  instances 
where  its  existence  is  self-evident,  there  are  others. 
Simpson,  of  Edinburgh,  has  of  late  shown,  with  his 
usual  masterly  skill,  the  important  relations  held  by 
that  condition  of  the  blood  evinced  by  albuminuria, 
whether  occasioned  or  not  by  pressure  of  the  en- 
larged uterus  upon  the  kidneys,  to  the  existence  and 
causation  of  puerperal  mania. J  Esquirol,  long  ago, 
called  attention  to  the  active  effect  produced  by  the 
inhalation  of  carbonic  acid  towards  the  induction  of 
insanity,  §  and  Dr  Workman,  in  the  letter  from  which 

'  *  Loc.  cit.,  p.  349. 

t  Trait*  des  Maladies  Mentiles,  p.  69. 
t  Clinical  Lectures  on  Diseases  of  "Women,  1863,  p.  443. 
§  "We  have  already  seen  that  those  occupations  which  expose  the  person  to 


IN    WOMEN.  63 

I  have  quoted,  speaks  of  the  tendencies  towards  de- 
lirium in  organic  pulmonary  disease,  and  the  fre- 
quency that  has  been  observed  of  latent  phthisis  in 
the  insane ;  points,  both  of  them,  that  are  probably 
to  be  explained  by  deficient  elimination  of  carbon 
from  the  blood.  It  will  not  be  strange,  moreover,  if 
it  is  found  that  in  a  similar  manner  may  be  inter- 
preted much  of  the  insanity  that  obtains  in  women, 
although  I  am  not  aware  that  this  suggestion  has 
before  been  made.  It  is  well  known  that  there  is  a 
close  sympathy  between  the  uterine  and  pulmonary 
systems,  depending  in  part,  it  may  be  presumed, 
upon  the  varying  quantities  of  carbon  discharged  by 
respiration  and  through  the  catamenial  fluid.  The 
evidences  of  this  sympathy  are  manifold,  and  familiar 
to  every  gynaecologist ;  they  are  furnished  alike  in 
health  and  disease,  explaining  many  types  of  the 
latter  that  were  otherwise  inexplicable,  and  account- 
ing, as,  for  the  first  time,  I  have  endeavored  to  show, 
for  the  fact  that  even  were  we  to  allow  chloroform  to 
be  dangerous  or  deadly  for  the  purposes  of  general 
surgery,  it  becomes  as  safe  as  ether,  to  which  it  is  for 
this  purpose  so  superior,  in  childbed,  being  here 
perfectly  innocuous,  if  properly  given.* 

The  so  frequent  uterine  asthma,  coincident  or  con- 

the  fumes  of  charcoal,  predispose  to  insanity.     We  ought  to  add,  that  asphyxia 
by  carbon,  is  very  liable  to  cause  dementia,  and  that  too  in  its  incurable  form." 
—  Mental  Maladies,  p.  54. 
•  Eutokia  ;  the  employment  of  Anaesthetics  in  Childbirth,  1863,  p.  aa 


64  REFLEX    IWSAMTY 

nected  with  the  catamenial  period,  is  an  instance  not 
irrelevant.  I  have  long  believed  and  taught,  that  in 
women  the  access  or  progress  of  pulmonary  phthisis 
is  frequently  dependent  upon  and  to  be  controlled  by 
the  menstrual  condition,  and  I  find  that  Dr.  Work- 
man has  announced  that  more  insane  women  than 
men  die  of  pulmonary  disease,*  which  is  so  far  con- 
clusive evidence. 

^^It  has  been  noticed,"  I  now  quote  from  Robinson, 
the  physician  to  the  Bensham  Asylum  at  Gateshead, 
but  every  one  is  familiar  with  the  fact,  "  that  among 
the  insane  generally,  the  circulation  of  the  blood  is 
feebly  performed,  and  in  melancholia  more  particu- 
larly, the  extremities  are,  from  this  cause,  cold  and 
benumbed,  while  the  surface  of  the  head  is  often 
unnaturally  heated.  Again,  in  acute  mania  notably, 
and  also  in  other  recent  forms  of  mental  disorder, 
the  quality  of  the  blood  is  evidently  much  impaired. 
Our  means  of  chemical  analysis  are  too  crude  to 
enable  us  to  express  in  scientific  formulae  the  precise 
additions  and  subtractions  which  constitute  this  par- 
ticular cachexia.  Suffice  it  to  state  that  the  peculiar 
odor  and  the  unequivocal  symptoms  of  disordered 
digestion,  secretion,  and  excretion  present  in  these 
cases,  clearly  show  that  the  blood  cannot  be  properly 
formed  and  purified,  and  that  its  condition  and  quality 

•  American  Journal  of  Insanity,  July,  1862. 


IN   WOMEN.  65 

must  therefore  be  faulty.  In  some  forms  of  insanitjf 
there  also  exists  an  unnatural  sensibility,  or  irritability 
of  ihe  mind  and  nervous  system,  and,  in  a  certain 
proportion  of  cases,  violent  mental  impressions  have 
originally  induced  the  disease. 

••  Moreover,  we  occasionally  observe  in  every  form 
of  mental  disturbance  a  serious  impairment  of  the 
innate  vitality  of  the  bodily  tissues  generally,  so  that 
a  slight  bruise  or  a  degree  of  pressure,  which,  under 
ordinary  circumstances,  would  produce  no  morbid 
effect  whatever,  will,  in  the  insane,  be  followed  by 
mortification  of  the  parts  and  ultimate  death."  *  This 
condition,  however,  is  more  apt  to  be  the  effect  of  the 
insanity  than  its  cause. 

On  the  other  hand,  "  it  should  also  be  remembered 
that  in  many  of  the  insane,  in  whom  there  is  indis- 
putable lesion  of  the  understanding,  the  most  careful 
scrutiny  will  fail  to  discover  any  disorder  of  the  cir- 
culation, as  indicated  by  the  pulse  and  respiration,  or 
of  the  functions  of  secretion  and  excretion,  as  indicated 
by  the  tongue,  alvine  evacuations,  or  the  renal  secre- 
tion. And,  with  the  exception  of  the  class  of  cases  to 
be  referred  to,  it  may  be  safely  affirmed,  that  among 
those  patients  whose  moral  nature  appears  to  be 
specially  invaded  by  disease,  derangement  of  the  phys- 
ical health  is  almost  as  frequent  as  among  those  whose 

•  Prevention  and  Treatment  of  Mental  Disorders,  p,  153. 

5 


66  REFLEX    INSANITY 

intellect  is  manifestly  disordered.  And  the  termination 
of  cases  of  moral  insanity  in  some  unmistakable  phys- 
ical disease,  as  general  paralysis,  will  not  unfrcquently 
solve  any  doubt  which  may  have  been  felt  previously, 
in  regard  to  the  disease  of  one  or  more  of  the  bodily 
organs. 

"  The  exceptional  class  we  have  spoken  of,  includes 
those  cases  of  perverted  moral  feeling  whose  history 
extends  back  to  their  earliest  infancy,  and  probably  to 
congenital  malformation  of  the  brain,"*  which,  if  not 
of  a  foetal  character,  may  be  owing  to  the  pressure 
exerted  upon  that  organ  during  the  latter  stage  of  a 
difficult  labor,  or  by  the  application  of  instruments 
during  delivery. 

We  are  not  then  to  find  in  diseases  of  the  blood,  or 
derangement  of  its  circulation,  a  causation  sufficient 
to  account  for  all  cases  of  insanity  which  are  ulti- 
mately of  extra-cerebral  origin.  We  must  seek  for 
other  methods  of  explanation,  one  of  which  is  un- 
doubtedly the  hereditary  tendency  so  often  recognized, 
and  which  may  exist  under  very  different  circum- 
stances than  those  ordinarily  noticed.  Thus,  for  in- 
stance, the  mental  disturbance  may  depend  not  merely, 
as  I  have  said,  upon  the  pressure  to  which  the  child's 
head  has  been  subjected  during  childbirth,  a  pressure 
sufficient,  in  many  cases,  to  effect  its  death,  and  in 
others   to   produce   convulsions   or   paralysis,   eithei 

•  Tuke,  loc.  cit.,  p.  189. 


IN    WOMEN.  67 

during  infancy,  or,  perhaps,  at  some  long  subsequent 
period  :  but  it  may  be  owing  to  an  effect  produced  in 
utero,  either  by  some  mental  aftection,  however  tem- 
porary, of  the  mother,  just  as  we  know  such  to  act, 
during  lactation,  upon  the  nursing  infant,  or  by  some 
functional  or  organic  affection  of  the  placental  or 
uterine  system.  Upon  this  point  I  could  say  much, 
but  shall  content  myself  by  again  presenting  evidence 
from  Dr.  Tuke. 

"  Should  it  be  said  that  disease  involves  a  changed  con- 
dition or  proportion  of  function  or  structure  in  one  or  more 
parts  of  the  body,  it  is  to  be  observed  that  this  change  may 
have  taken  place  at  a  period  when  it  would  escape  notice,  or 
even  during  fcetal  life.  During  the  latter  period,  diminished 
nutrition  of  the  body,  or  diminished  nutrition  of  one  part 
and  increased  nutrition  of  another,  may  have  occurred,  and 
thus  resulted  in  the  production  of  an  undue  proportion  or 
predominance  of  a  function.  Hypertrophy  of  some  textures 
has  been  observed,  frequently  coexisting  with  atrophy  of 
others,  perverted  nutrition  being  often  combined  with  ex- 
cessive or  defective,  and  several  of  these  different  changes 
often  occurring  in  succession,  in  consequence  of  the  opera- 
tion of  the  same  causes.  There  is,  indeed,  during  foetal 
life  —  and  we  may  practically  widen  this  period,  and  say 
during  that  which  elapses  before  the  character  is  or  can  be 
observed  —  abundant  opportunity  for  the  influence  of  per- 
verted nutrition ;  whether  it  be  in  the  formation  of  cell- 
germs,  their  passage  into  cells,  or  the  subsequent  processes 
connected  with  the  growth  and  organization  of  the  tissues; 
or,  again,  whether  the  elements  of  the  circulating  blood  be 
in  an  abnormal  proportion;  or,  lastly,  whether  it  be  the 
mysterious  but  well-recognized  principle,  in  virtue  of  which 
there  is  an  hereditary  predisposition  to  disease,  which  rules 
over  and  perverts  the  nutritive  processes.  Thus,  in  a  case 
of  what  would  probably  be  regarded  as  congenital  moral  im- 


68  REFLEX    INSANITY 

becilitj,  the  mother  of  the  f)atient  was  the  subject  of  malig- 
nant disease  of  the  uterus  during  gestation.  Now  it  is  pos- 
sible that  this  condition  of  the  mother  interfered  with  the 
proper  nutrition  of  the  cerebral  tissue  of  the  foetus,  and  was 
one,  among  other  causes,  which  contributed  to  the  final 
result.  Persons  born  with  talipes,  or  strabismus,  owe  their 
defect  to  some  defect  of  embryo  life.  In  like  manner,  during 
the  same  period  of  existence,  the  brain  may  undergo  patho- 
logical changes  which  induce  defective  mental  or  moral 
power."* 

"  The  emotional  theory,  which  Bucknill  believes  to 
be  the  true  explanation  of  the  metaphysical  nature  of 
insanity,  goes  to  prove  only  this  —  that  emotional 
disturbance  is  the  frequent  source  and  the  constant 
accompaniment  of  mental  disease.  It  is  so  far  prac- 
tical as  opposed  to  the  theory  upon  which  the  dogmas 
of  courts  of  law  have  been  founded,  that  insatiity  is  a 
perversion  solely  of  the  thinking  faculties,  but  it  is 
quite  consistent  with,  and  indeetl  subservient  to,  the 
opinion  that  the  proximate  cause  of  all  mental  disease 
is  to  be  referred  solely  to  the  abnormal  state  of  the 
brain,"  f  the  ultimate  cause  in  many  instances  having 
to  be  sought  also  in  bodily  and  structural  change,  but 
in  parts  far  distant  from  that  organ. 

In  justice  to  an  earlier  author,  Pinel,  it  should  be 
remarked  that,  however  mistaken  his  views  upon  the 
pathology  of  insanity  may  have  been,  they  had  at 
least  the  merit  of  referring  a  bodily  disease  to  a  bodily 
origin.     In  the  preface  to  the  second  edition  of  his 

•  Tuke,  loc.  cit,  p.  186.  t  Ibid.,  p.  447- 


IN   WOMEN.  69 

work,  he  thus  wisely  expresses  an  emphatic  condem' 

nation  of  metaphysical  theories  on  this  point :  — 

"  The  most  difficult  part  of  natural  history  is,  without 
doubt,  the  art  of  well  observing  internal  diseases,  and  of 
distinguishing  them  by  their  proper  characters.  But  mental 
alienation  presents  new  and  diverse  difficulties  and  obstacles 
to  surmount,  either  in  the  unusual  gestures  and  tumultuous 
agitations  which  it  occasions,  or  in  a  kind  of  disordered  and 
incoherent  chatter,  or  in  a  repulsive  or  savage  exterior.  If 
one  desires  to  account  for  the  phenomena  observed,  one  has 
to  fear  another  rock  —  that  of  intermingling  metaphysical 
discussions  and  divagations  of  ideology  with  a  science  of 
facts."  * 

He  goes  still  further,  and  with  an  acumen  re- 
markable in  view  of  the  limited  method  of  diagnosis 
then  known,  he  foreshadows  the  great  theory  of  a 
frequent  pelvic  origin,  for  he  refers  the  primitive  seat 
of  mania  ''  to  the  region  of  the  stomach  and  intestines, 
from  whence,  as  from  a  centre,  the  disorder  of  the 
understanding  is  propagated  by  a  species  of  irradia- 
tion. A  feeling  of  constriction,  &c.,  manifests  itself 
in  these  parts,  soon  followed  by  a  disorder  and  trouble 
of  ideas."  t  In  that  day,  it  will  be  remembered,  the 
methods,  by  which  at  the  present  time  the  differential 
diagnosis  of  most  of  the  diseases  of  the  abdomen  is 
so  clearly  and  so  easily  established,  were  in  practice 
almost  wholly  unknown. 

We  have  thus  been  brought  to  the  doctrine  that 
mental  disturbance   may  be  occasioned  secondarily 

•  Tuke,  p.  394  t  Ibid.,  p.  393. 


70  REFI-EX    INSANITY 

and  reflexly,  by  sympathy  with  disturbances  of  other 
organs  than  the  brain.  Let  us  listen  upon  the  gen- 
eral subject,  to  Dr.  Bucknill. 

"That  the  organ  of  the  mind  is  thrown  into  diseased 
action  by  sympathy  with,  that  is,  by  suffering  with,  other 
diseased  or  injured  parts,  is  scarcely  less  certain  than  that 
the  stomach,  the  heart,  or  the  spinal  marrow  are  so  affected. 
The  modus  operandi  of  this  cause  of  disease  is  by  no  means 
clearly  intelligible,  either  in  relation  to  the  brain  or  to  other 
organs;  the  explanations  usually  offered  being  little  more 
than  diversified  verbal  formularies  of  the  fact.  Thus,  when 
we  say  that  the  irritation  of  the  cervix  uteri  is  reflected  upon 
the  stomach,  occasioning  vomiting  and  distress  in  that  or- 
gan, we  come  no  nearer  to  an  explanation  of  the  mode  of 
action  than  when  we  say  that  the  stomach  sympathizes  with, 
or  suffers  in  conjimction  with,  or  in  consequence  of,  irrita- 
tion of  the  organ  first  affected.  And,  in  like  manner,  when 
we  say  that  the  brain  suffers  sympathetically  with  the  uterus 
or  stomach,  we  use  a  mere  verbal  formula  for  the  colligation 
of  two  facts,  with  the  intimate  nature  of  whose  connection 
we  are  wholly  unacquainted.  The  knowledge  which  we 
actually  possess  on  this  subject  may,  in  general  terms,  be 
thus  stated :  the  most  important  organs  of  the  body  are 
liable  to  be  thrown  into  states  of  functional  disturbance  by 
irritation  or  injury  of  other,  and  frequently  of  distant  parts. 
The  liability  to  this  disturbance  depends,  in  the  first  place, 
upon  what  is  called  constitutional  irritability,  or  a  state  of 
the  system  in  which  slight  causes  of  nervous  action  produce 
great  effects;  and,  in  the  second  place,  upon  the  intimate 
connection  of  the  organ  secondarily  affected,  with  the  ner- 
vous system,  and  its  liability  to  be  thrown  into  disorder  by 
any  alteration  or  disturbance  in  the  state  of  that  system. 
Any  premature  attempts  to  explain  this  important  patho- 
logical fact  by  hypothesis,  respecting  nervous  currents,  or 
the  exhaustion  of  nervous  power,  seem  at  present  rathet 
likely  to  obscure  than  elucidate  the  matter.  We  may,  how- 
ever, come  one  step  nearer  to  the  view  of  the  fact,  by  con* 


IX    WOxMEN.  71 

sidering  all  sympathetic  disturbance  as  taking  place  in  the 
nervous  system  itself;  and  in  viewing  the  functional  dis- 
turbance of  secreting  and  other  organs,  as  merely  the  ex- 
pression of  abnormal  states  of  the  nerves  in  those  organs. 
Strictly  speaking,  therefore,  sympathetic  vomiting  or  palpi- 
tation is  as  purely  a  nervous  phenomenon  as  loss  of 
consciousness  or  convulsions;  and  the  latter,  as  mental 
excitement  or  delusion. 

"In  early  life,  the  cerebro-mental  functions  are  more  in- 
timately connected  with  those  of  the  spinal  system  than  at 
subsequent  periods,  and  distant  irritations  are  more  frequent 
and  efficient  causes  of  mental  disturbance  in  the  infant  than 
in  the  adult.  Delirium  and  coma  are,  in  children,  fre- 
quency produced  by  intestinal  irritation.  In  the  adult,  in 
comparison  with  convulsions,  delirium  is  so  rarely  a  conse- 
quence of  simple  irritation,  that  it  furnishes  one  strong 
proof  that  the  brain  proper  exercises  its  functions  with 
great  independence  of  the  excito-motory  or  spinal  system. 
The  most  frequent  and  unquestionable  instances  of  cerebral 
disturbance  from  distant  irritation  or  sympathy,  are  afforded 
in  epilepsy  and  hysteria.  In  both  of  these  diseases  the 
paroxysm  is  compounded  of  disturbance  both  of  the  cere- 
bral and  spinal  functions;  but  during  the  interval,  cerebral 
disturbance  alone  is  frequently  present,  and  in  the  paroxysm 
itself  it  is  never  wanting.  In  epilepsy,  especially,  is  this  the 
case;  for  loss  of  consciousness,  which  is  the  primary  and 
leading  feature  of  the  paroxysm,  is  the  most  serious  and 
profound  indication  of  cerebral  disturbance,  no  less,  in  fact, 
than  the  temporary  abnegation  of  all  cerebral  function.  In 
hysteria,  loss  of  consciousness  is  of  less  certain  occurrence, 
although  sometimes  it  is  doubtless  complete.  In  the  inter- 
val of  hysteria,  however,  cerebral  disturbance  is  not  less 
marked  than  in  epilepsy.  The  emotions  are  perverted,  and 
even  delirium  is  by  no  means  uncommon.  Now  both  of 
these  diseases  are  frequently  but  the  expression  of  sympathy 
with  irritation  of  distant  parts  of  the  nervous  system.  The 
one  is  produced  by  irritation  of  the  nerves  of  the  uterus  and 
its  appendages,  and  the  other  by  the   irritation  of  almost 


72  REPLBX    INSANITY 

any  portion  of  the  peripheral  nerves,  by  worms  in  the  intes- 
tines, renal  calculus,  painful  injuries,  and  diseases  of  the 
limbs,  &c.  Therefore  these  diseases  present  unquestionable 
instances  of  mental  disturbance,  occasioned  by  sympathy 
of  the  brain  with  irritation  of  the  distant  nerves;  of  the 
central  organ  of  the  system,  suffering  in  its  noblest  func- 
tions, in  sympathy  with  some  fibres  of  its  peripheral  ex- 
tension. 

"The  most  probable  explanation  of  these  sympathetic 
disorders  is,  that  injury  to  one  part  of  the  nervous  system 
interferes  with  the  processes  of  secondary  nutrition  taking 
place  in  other  parts.  The  rapidity  with  which  they  occur 
may.  at  first  sight,  seem  adverse  to  this  view;  for  instance, 
in  the  case  related  by  Dr.  Gooch,  and  so  familiar  to  psychol- 
ogists, where  Dr.  Denman  passed  a  ligature  round  a  polypus 
of  the  fundus  of  the  uterus;  as  soon  as  he  tightened  it,  he 
produced  pain  and  vomiting.  As  soon  as  the  ligature  was 
slackened,  the  pain  ceased;  but  whenever  he  attempted  to 
tighten  it,  the  pain  and  vomiting  returned.  The  ligature 
was  left  on,  but  loose.  The  patient  died  about  six  weeks 
afterwards,  and,  on  opening  the  body,  it  was  found  that  the 
uterus  was  inverted,  and  that  the  ligature  had  included  the 
inverted  portion.  Sympathetic  disturbances  of  the  func- 
tions of  the  brain  are,  in  some  instances,  scarcely  less  rap- 
idly occasioned,  or  capable  of  receiving  more  immediate 
relief.  Thus  the  irritation  of  a  cutting  tooth  will  sometimes 
produce  in  a  child  delirium  and  coma;  and  the  removal  of 
the  irritation,  by  incision  of  the  inflamed  gum,  will  remove 
the  symptoms  almost  as  speedily  as  in  the  examples  above 
quoted.  But  when  it  is  considered  that  the  processes  of 
secondary  nutrit'on  are  those  upon  which  the  functions  of 
all  organs  immediately  depend,  and  that  any  interference 
with  these  processes  must  necessarily  and  immediately  dis- 
turb the  normal  course  of  the  functions,  the  short  interval 
which  is  frequently  observed  to  exist  between  the  produc- 
tion of  irritation  and  its  sympathetic  consequences  will  pre- 
sent no  difficulty  to  the  theory  which  explains  the  latter  in 
the  manner  here  suggested.     In  our  present  state  of  igno- 


IN    WOMEN.  73 

ranee  of  the  manner  in  which  influences  are  communicated 
from  one  part  of  the  nervous  system  to  other  parts,  it  is  im- 
possible to  explain  how  the  processes  of  secondary  nutrition 
in  the  nervous  structure  are  interfered  with  in  distant  parts 
thereof.  But  this  difficult^'  scarcely  diminishes  the  proba- 
bility that  the  explanation  offered  is  the  true  one;  and, 
indeed,  only  presents  one  of  those  imperfect  links  in  reason- 
ing, which  the  immaturity  of  physiological  science  renders 
of  such  constant  occurrence  in  all  departments  of  medicine. 
The  operation  of  remedies  is  consistent  with  this  view  of 
sympathetic  disturbance,  since  those  narcotic  substances 
which  retard  the  processes  of  waste  and  repair  in  the  ner- 
vous system  afford  the  most  efficient  means  of  preventing  the 
nervous  function  from  suffering  hi  consequence  of  periph- 
eral nervous  injury.  Moreover,  this  view  6f  pathological 
sympathy  is  consistent  with  the  only  rational  view  of  phys- 
iological sympathy.  Secretions  are  the  result  of  secondary 
nutrition.  Many  secretions  are  normally  excited  by  the 
irritation  of  nerves  more  or  less  distant;  that  of  the  mam- 
ma, for  instance,  of  the  testis,  and,  to  some  extent,  of  the 
gastric  glands.  Here,  then,  at  least,  are  processes  of  sec- 
ondary nutrition,  energetically  influenced  by  the  irritation 
of  distant  nerves."  * 

Marshall  Hall  himself  could  scarcely  have  afforded 
us  a  juster  and  more  thorough  argument  for  all  the 
effects  I  have  claimed,  of  pelvic  agencies  as  ulti- 
mately causing  insanity  in  w^omen,  than  the  remarks 
above  given. 

It  has  been  argued  that  those  of  us  who  see  in  re- 
flex action  an  explanation  of  what  would  be  other- 
wise inexplicable  anomalies,  must  be  in  error  on  the 
ground  that,  by  allowing  a  distant  lesion  ever  to  pro- 
duce disturbance  of  the  brain,  we  ought  always  to 

•  Loc  cit.,  pp.  38>-385. 


74  REFLEX    INSANITY 

find  an  identical  effect  from  a  similar  cause.     Tlie 

fallacy  of  such  an  expectation  has  been  commented 

upon   by  Dr.  Williams   in  the  following   language, 

equally  applicable  to  congestion  and  other  morbid 

conditions  of  the  brain  :  — 

"  Congestion  of  the  liver  is  sometimes  accompanied  by 
pain  or  tenderness;  sometimes  it  is  without  either.  Con- 
gestion of  the  stomach  sometimes  causes  gastralgia,  nausea, 
and  vomiting,  with  altered  appetite;  but  these  symptoms 
are  often  absent  when  the  amount  of  disease  of  the  liver, 
or  the  heart,  and  the  subsequent  occurrence  of  haemateme- 
sis,  leave  no  doubt  that  the  stomach  was  congested.  The 
same  remark  is  applicable  to  the  kidneys,  the  uterus,  the 
brain,  and  other  organs."  * 

On  the  other  hand,  that  in  cases  where  mental  dis- 
turbance is  thus  induced,  it  should  often  be  extreme, 
varying  alike  in  its  type,  its  symptomatic  characters, 
and  its  degree  of  intensity,  is  only  what  should  a 
■priori  have  been  expected.  Dr.  Bucknill  has  clearly 
recognized  this  fact,  and  admits  that  the  analogy  from 
an  organ  whose  function  is  simple,  to  one  whose 
function  is  so  complex  as  that  of  the  brain,  can  afford 
but  a  slight  insight  into  the  effect  of  similar  pathologi- 
cal conditions  in  the  two  instances.  Of  the  abdom- 
inal and  thoracic  organs,  the  stomach  is  that  whose 
functions  are  the  least  simple.  Its  muscular  move- 
ments are  as  ingeniously  adapted  to  an  end  as  are  those 
of  the  heart ;  they  are  even  more  complicated  and 
less  mechanical.     In  addition  to  this,  the  functions 

♦  Principles  of  Medicine. 


IN   WOMEN.  75 

of  secretion  and  absorption,  discharged  by  its  several 
sets  of  glands,  add  to  the  complexity  of  its  duties. 
Congestion,  as  we  have  seen,  causes  irregular  excite- 
ment or  depression  of  all  its  functions,  nei-vous,  mus- 
cular, and  secretive ;  yet,  compared  with  the  brain, 
how  few  and  simple  are  its  duties.  The  functions  of 
the  organ  of  the  mind  are  more  numerous  than  those 
of  all  other  parts  of  the  body  put  together ;  nor  less 
distinct  in  themselves  and  inter-distinct  ifl  their  ac- 
tion. Consequently,  any  pathological  state  which 
destroys  their  equilibrium,  producing  irregular  de- 
pression of  some  functions,  with  irregular  excitement 
of  others,  must  cause  a  wider  and  more  intricate 
range  of  anomalies  than  is  observable  in  a  similar 
state  of  the  more  simple  organs.* 

It  is  necessary  to  distinguish  the  distant  affections 
which  cause  insanity  from  those  that  merely  accom- 
pany or  result  from  mental  disturbance.  I  have 
already  referred  to  Dr.  Workman's  estimate  of  the 
frequency  and  importance  in  the  insane,  of  pulmo- 
nary phthisis,  here  so  often  latent  or  unnoticed,  even 
to  its  extreme  stages.  The  physician  of  the  Devon 
Asylum  would  explain  this  and  similar  affections  in 
the  insane  as  follows:  — 

"Diseases  of  the  lungs  occur  in  the  insane  in  all  their 
varieties.  Thej  are  frequently  latent  from  the  absence  of 
cough,  and  the  patient's  absorption  of  mind  preventing  com* 

•  Loc.  cit.,  p.  359. 


76  REFLEX    INSANITY 

plaint.  The  absence  of  cough  in  serious  pulmonary  disease 
is  very  peculiar.  In  dementia,  it  arises  partly  from  torpor 
of  the  excito-motory  system,  partly  from  loss  of  attention; 
from  the  same  cause,  in  fact,  as  the  frequent  dirty  habits  of 
the  insane.  In  mania,  it  arises  from  the  attention  being 
intensely  pre-occupied  by  the  vivid  ideas  and  delusions 
which  absorb  the  mind.  We  have  seen  many  patients  in 
advanced  stages  of  phthisis,  who  were  never  heard  to  cough 
80  long  as  they  were  under  the  influence  of  maniacal  excite- 
ment. When  this  underwent  a  temporary  diminution,  they 
were  greatly  troubled  with  cough,  which  was  again  arrested 
by  the  recurrence  of  excitement.  The  continuance  of  colli- 
quative diarrhoea  and  perspiration,  and  of  emaciation, 
proved  that  there  was  no  halt  in  the  progress  of  the  disease, 
as  the  absence  of  cough  has  led  authors  erroneously  to  sup- 
pose. The  torpor  of  the  nervous  system  in  dementia  leads 
to  another  peculiarity  in  the  lung  and  in  some  other  bodily 
diseases  of  the  insane,  namely,  the  absence  of  irritative  or 
symptomatic  fever;  and  hence  it  happens,  that  in  a  de- 
mented person  whose  strength  is  unimpaired,  and  whose 
constitution  is  tolerably'  good,  diseases  will  obtain  a  high 
degree  of  development,  with  symptoms  so  few  or  obscure  as 
to  be  incredible  to  the  general  physician.  It  is  on  this  ac- 
count that  the  numerous  sloughing  sores  to  which  general 
paralytics  are  liable,  produce  so  little  suflfering  or  constitu- 
tional irritation.  We  have  known  the  stomach  disorganized 
by  cancer,  without  the  patient  complaining  of  any  pain 
until  a  few  days  before  death,  when  perforation  took  place. 
The  only  case  of  true  carditis  we  ever  saw,  occurred  in  an 
insane  person  who  complained  of  no  pain,  and  in  whose 
heart  disease  was  only  suspected  twenty-four  hours  before 
deaths  in  consequence  of  the  failure  of  the  pulse.  This  pe- 
culiarity in  the  intercurrent  diseases  of  the  insane  should 
teach  the  physician  to  observe  with  watchful  anxiety  every 
physical  indication  from  which  he  can  derive  knowledge  of 
the  attack  of  disease  before  it  is  so  advanced  as  to  be  beyond 
control.     Pulmonary  gangrene  is  more  common  among  the 


IN    WOMEN.  77 

insane  than  the  sane ;  but  not  to  the  same  extent  here  as  at 
Vienna,  where  it  contributes  largely  to  asjhun  mortality."* 

To  my  own  mind,  it  would  be  more  scientific  and 
in  accordance  with  facts  to  explain  the  non-apprecia- 
tion of  pain  in  the  insane  by  a  true  state  of  general 
or  local  anaesthesia,  a  temporary  and  intermittent,  or 
confirmed  and  permanent,  paralysis  of  the  nerves  of 
sensation,  local  and  limited  or  general  as  this  may  be, 
than  to  attribute  it  merely  to  lack  of  notice  of  the 
suffering,  in  consequence  of  pre-engagement  or  pre- 
occupation of  the  mind.  That  I  am  correct  would 
seem  to  be  shown,  moreover,  by  the  curious  fact  that 
there  is  often  absent  in  the  insane  the  febrile  excite- 
ment and  reaction,  both  nervous  and  arterial,  that 
usually  attend  physical  accident  or  disease.  That 
intervals  may  occur,  in  which  the  patient  becomes 
acutely  sensible  of  bodily  anguish,  only  implies  that 
aesthesia  or  even  hyperaesthesia  may  succeed  to  local 
or  general  anaesthesia,  just  as  undue  mental  activity 
may  at  times  alternate  with  apathy  or  even  dementia 
itself. 

VI.  —  Causation  of  Insanity  often  Pelvic 
IN  Women. 

I  have  claimed  that  while  there  are  affections  of 
many  organs  in  the  body  in  both  sexes,  that  undeilie 

•Loc.  cit.,  p.  433. 


jrS  REFLEX   INSANITY 

insanity,  being  in  reality  its  cause,  and  the  foundation 
upon  which  it  rests,  in  women  there  is  a  depth  be- 
yond—  a  source  of  excitation  not  existing,  practically, 
in  man  ;  for,  allowing  every  latitude  to  the  influence 
of  the  sexual  system  in  the  male,  it  must  be  allowed 
that  in  him  the  genital  apparatus  is  merely  subsidi- 
ary, and  playing  but  an  occasional  and  comparatively 
a  very  insignificant  part  in  its  relations  to  the  general 
economy. 

In  woman,  the  case  is  very  different.  Not  only  is 
she  subject  to  a  host  of  diseases  peculiar  to  her  sex, 
to  which  we  find  neither  homologue  nor  analogue  in 
man,  but  they  are  capable  of  so  modifying  herself  as 
entirely  to  change  her  natural  disposition  and  charac- 
ter. In  health,  we  find  her  still  obedient  to  a  special 
law.  The  subject  here  also,  we  might  even  say  the 
victim,  of  periodicity,  her  life  is  one  perpetual  change, 
and  these  changes  even  are  still  again  subdivided. 

The  uterus  and  appendages  that,  in  the  female  em- 
bryo, while  yet  unborn,  were  being  developed  ;pari 
passu  with  the  other  organs  of  the  body,  become  at 
birth  arrested  in  their  growth  ;  without  other  change 
than  a  slight  and  disproportionate  enlargement  in 
size,  they  remain  in  their  foetal  condition  until  pu- 
berty occurs.  The  child  has  now  become  a  maiden. 
Immediately  the  emotions,  desires,  and  passions  that, 
though  latent,  have  been  gradually  foreshadowing 
themselves,  are  now  established,  unrecognized  though 


IN    WOMEN.  79 

they  may  be  by  the  girl  herself;  yet,  like  the  smoulder- 
ing fires  of  a  volcano,  ready  to  burst  forth  at  any  ex- 
citing moment.  The  short  space  of  a  lunar  month  is 
henceforward  the  field,  for  many  years,  of  a  triple 
change  —  preparation  for  ovulation,  the  discharge  of 
a  germ  fit  for  impregnation,  rest  and  recuperation. 
The  instinctive  yearning  for  the  other  sex,  and  its 
gratification  in  the  excitement  of  coitus,  the  culmina- 
tion of  sexual  congress  in  effectual  impregnation,  are 
surely  of  no  little  import ;  as  they  are  affairs  of  con- 
stantly recurring  occurrence,  both  in  the  married  and 
in  many  of  the  unmarried,  unless,  as  is  too  offien  the 
case,  they  are  interfered  with  by  preventive  or  sub- 
versive measures,  which  may  but  increase  their  eflfects 
upon  the  woman's  system  by  making  them  prejudi- 
cial rather  than,  as  otherwise,  of  benefit.  Pregnancy 
with  its  varying  fortunes,  childbed  and  lactation, 
and,  finally,  the  grand  climacteric,  supervene,  and  a 
return  to  the  second  sexual  childhood,  which,  though 
barren  of  further  fruit  to  the  womb,  is  yet  by  no 
means  past  desire  and  attempts  at  its  gratification,  or 
past  uterine  disease  and  its  many  dangers :  with  this 
the  scene  is  closed. 

To  man,  these  changes,  these  excitements,  this 
special  work,  these  diseases,  these  dangers,  are  all 
unknown.  Why,  then,  is  it  called  preposterous  to 
seek  in  her  sex  the  abstract  fundamental  influence 
impressed  upon  evei"y  woman,  even  while  an  infant 


8o  REFLEX    INSANITY 

in  her  mother's  womb,  the  solution  of  much  to 
which  otherwise  we  have  no  key?  Van  Helmont 
was  not  far  wrong  when  he  contended  that  woman 
was  what  she  is,  in  health,  in  character,  in  her  charms, 
alike  of  body,  mind,  and  soul,  because  of  her  womb 
alone. 

Nor  am  I  so  far  wrong,  I  candidly  believe,  in  at- 
tributing the  major  part,  not  all,  of  her  characteristics 
in  disease,  mental  as  well  as  bodily,  also  to  this  self- 
same womb.  Just  as  we  have  special  diseases  of  the 
pelvic  organs  in  the  female,  so  we  may  have  function- 
al diseases  of  the  brain,  of  many  and  deceptive  types, 
excited  in  her  thereby  ;  and  just  as  we  may  have  other 
disease  in  woman,  whether  general  in  its  character  or 
of  other  than  uterine  localization,  pulmonary,  cardiac, 
renal,  or  hepatic,  as  the  case  may  be,  idiopathic  in  its 
inception,  yet  materially  modified  by  the  influence  of 
the  sexual  system,  even  so  there  may  exist  states  of 
mental  disturbance  in  which  we  may  recognize  an 
originality  of  causation  in  the  brain  itself,  but  yet  such 
an  effect  from  a  special  physiological  or  pathological 
condition  of  the  uterus  or  ovaries  that  may  be  present, 
as  to  require  special  examination,  special  considera- 
tion, and  special  treatment.  To  the  gynaecologicil 
expert,  these  facts  will  be  self-evident.  I  have  found 
that  to  some  psychological  experts  they  have  not  been 
so.  As  my  object  is  merely  to  change  to  a  more  ra- 
tional system  the  present  private  and  public  treatment 


IN   WOMEN.  8 1 

of  SO  many  of  the  most  interesting  of  patients,  now 
practically  untreated  at  all,  I  shall  again  present  the 
testimony  of  psychologists  rather  than  my  own.  In 
my  previous  writings  I  have  contended  that  the  prin- 
ciples to  which  I  had  called  attention  have  long  been 
known,  though  in  practice  constantly  unappreciated 
or  forgotten.  I  shall  now  go  farther,  and  by  the  testi- 
mony presented,  which  is  but  a  little  fraction  of  that 
I  now  have  at  hand,  show,  as  I  think,  conclusively, 
that  in  longer  refusing  for  the  female  insane  that  study, 
special  examination,  and  treatment,  without  which,  in 
all  other  forms  of  disease,  women  cannot  be  properly 
cared  for,  any  person  laying  claim  to  the  honorable 
office  of  physician  must  be  deemed  guilty  of  gross 
neglect,  blindness  from  too  great  conservatism,  or 
inhumanity.  This  is  strong  language :  it  is  not  in- 
tended as  personal,  however.  I  am  but  working  for 
a  general  principle  in  one  of  the  many  fields  of  its 
application,  and  in  behalf  of  the  sex,  to  the  alleviation 
of  whose  sufferings  some  of  us  are  devoting  our  lives. 
Should  controversies  be  attempted  to  be  forced  upon 
me,  as  has  already  been  the  case  in  the  discussion 
of  this  question,  it  is  to  the  good  sense  and  wisdom 
of  the  profession  that  I  shall  again  appeal. 

I  cannot  do  better,  at  this  point  of  our  inquiry,  than 
introduce  the  testimony  of  a  gentleman  at  present,  or 
very  lately,  connected  with  the  Utica  Asylum. 

"  When  we  contemplate  the  reproductive  system,  whether 
6 


83  REFLEX   INSANITY 

in  health  or  disease,"  says  Dr.  Kellogg,  "  in  its  relations  to 
the  cerebral  system  and  to  psychology,  we  are  forcibly  struck 
with  the  paucity  and  imperfection  of  our  knowledge.  The 
recorded  facts  which  bear  upon  the  reciprocal  influence  of 
these  systems  are  widely  scattered,  and  the  attempt  to  collect, 
digest,  and  systematize  them,  and  make  the  necessary  scien- 
tific deductions,  would  be  a  work  of  some  importance.* 

"  The  influence  of  excessive  and  unnatural  excitement  of 
the  sexual  organs  upon  the  mental  faculties,"  he  continues, 
*'  has  long  been  recognized.  In  tables  setting  forth  the  sup- 
posed causes  of  insanity,  this  has  long  occupied  a  prominent 
place ;  and  though  its  influence  as  a  cause  of  insanity  has  no 
doubt  been  overrated  (or  misinterpreted,  in  the  absence  of 
physical  examinations  in  women,  —  H.  R.  S.),  still  it  is  un- 
doubtedly great.f  Of  the  probable  causes  of  derangement 
in  three  hundred  and  sixty-six  cases  of  insanity,  occurring 
in  both  sexes,  —  as  recorded  in  the  report  of  the  superintend- 
ent of  the  New  York  State  Lunatic  Asylum,  for  the  year 
1852,  —  eighty-seven,  or  nearly  one  fourth  of  the  whole  num- 
ber of  cases,  are  reported  to  have  arisen  from  causes  directly 
connected  with  the  reproductive  system.  In  the  report  of 
the  superintendent  of  the- same  institution  for  the  year  1858, 
of  the  supposed  causes  of  insanity  in  four  hundred  and 
twenty-four  cases,  one  hundred  and  seventeen,  or  more  than 
one  fourth,  appear  to  have  had  direct  connection  with  some 
disturbance  of  the  sexual  organs.  In  the  able  and  interest- 
ing report  of  Dr.  Gray  to  the  managers  of  this  institution, 
for  1853,  of  three  hundred  and  ninety  cases,  seventy-two  are 
supposed  to  have  had  some  direct  connection  with  derange- 
ment of  these  organs.  From  the  above,  it  would  appear  that 
in  nearly  one  fourth  of  all  the  cases  of  insanity,  occurring  in 
both  sexes,  the  disturbance  of  the  generative  organs  was  so 
marked  as  to  be  regarded  as  a  primary  cause  of  the  mental 
derangement. 

•  Considerations  on  the  Reciprocal  Influence  of  the  Physical  Organization  and 
Mental  Manifestations.  —  Amer.  Journal  of  Insanity,  April,  1856,  p.  305 

t  See  the  testimony  of  the  late  Dr.  Brigham,  in  the  Philips'  Will  case.  — 
Amer.  Journal  of  Insanity,  vol.  vi.  p.  183. 


IN   WOMEN.  83 

"Whether  the  primary  cause  in  these  cases  had  its  seat  in 
the  cerebral  or  the  generative  system,  is  a  question  no  less 
interesting  than  difficult  of  solution,  and  one  which  could 
only  be  determined  by  an  attentive  consideration  of  the  his- 
tory of  the  cases  reported,  and  a  close  observance  of  the  true 
sequence  of  the  symptoms  in  each,  and,  whether  the  primary 
link  in  the  chain  of  morbid  sympathies  had  its  seat  in  the 
one  system  or  the  other,  it  is  none  the  less  important  in  re- 
lation to  the  reciprocal  influence  of  the  two. 

"  As  the  functions  of  the  reproductive  system  are  far 
more  important  and  intricate  in  the  female  than  in  the  male 
economy,  and  as  the  pathological  disturbances  are,  as  a 
natural  consequence  of  this,  more  frequent  and  interesting, 
we  are,  as  a  matter  of  course,  to  look  to  the  female  genera- 
tive system  for  the  most  important  illustrations  of  the  sym- 
pathetic disturbances  and  reciprocal  influences  dependent 
upon  these  pathological  lesions.  Hence,  all  the  diseases 
which  aflfect  the  female  generative  system  have,  at  one  time 
or  another,  been  brought  forward  as  causes  of  insanity. 
Even  its  most  natural  function,  that  of  gestation,  does,  in 
some  cases,  by  the  peculiar  change  wrought  in  the  female 
economy,  and  the  train  of  inexplicable  symptoms  which  re- 
sult, give  rise  to  insanity ;  and  there  are  cases  on  record,  of 
females  who  have  been  positively  insane  during  the  whole 
of  each  period  of  utero- gestation,  but  who  recovered  their 
mental  health  and  strength  soon  after  delivery.  The  cases 
in  which  some  slight  mental  or  moral  disturbance  during 
gestation  has  been  observed  are  numerous;  there  are  many 
on  record,  and  every  experienced  practitioner  is  able,  no 
doubt,  to  recall  to  mind  such  slight  disturbances. 

"  The  influence  which  the  menstrual  function,  even  when 
performed  apparently  in  a  healthy  manner,  exercises  upon 
the  mental  faculties  and  moral  feelings  of  some  females  is 
exceedingly  interesting  to  the  intelligent  and  philosophical 
observer.  In  certain  abnormal  states  of  this  function  the 
influence  is  still  more  apparent.  I  have  been  told  by  in- 
telligent females,  accustomed  to  analyze  their  own  feelings, 
that  they  felt  far  less  mental  energy  during  this  state  than 


84  REFLEX    INSANITY 

in  the  intervals,  and  that  they  possessed  far  less  control  over 
the  moral  feelings  than  at  other  times,  were  more  easily 
excited,  and  that  the  most  trifling  circumstances,  which  at 
other  times  would  pass  unheeded,  have,  in  spite  of  every 
eflfort,  greatly  disturbed  their  equanimity.  In  some  whom  I 
have  known,  of  a  nervous,  excitable  temperament,  their 
whole  character  appeared  changed  during  the  menstrual 
period,  and  from  being  cheerful,  kind,  firm,  patient,  and 
decided,  they  became  morose,  taciturn,  wayward,  fidgety, 
and  impatient,  frequently  manifesting  a  certain  nervous 
irritability  bordering  on  hysteria,  and  were  sometimes  over- 
come by  paroxysms  of  that  interesting  affection. 

"  The  changes  which  take  place  in  the  mental  and  moral 
faculties  about  the  time  of  puberty,  are  in  both  sexes  very 
interesting,  particularly  so  with  the  female.  These  have 
been  frequently  alluded  to  by  medical  writers,  as  attendant 
upon  a  fuller  development  and  higher  manifestations  of 
vitality  in  the  sexual  organs.  During  these  changes  the 
nervous  system  exhibits  increased  susceptibility  and  sensi- 
bility; and  not  only  the  whole  frame,  but  also  the  mental 
manifestations,  present  greater  activity  of  development." 
"  The  mind,"  says  Dr.  Copland,  "  acquires  extended  powers 
of  emotion  and  passion,  and  the  imagination  becomes  more 
lively.  If,  on  the  other  hand,  the  uterine  organs  continue 
undeveloped,  and  the  menstrual  discharge  does  not  appear, 
the  mind  is  dull,  weak,  or  depressed,  and  the  emotions  and 
passions  are  imperfect  or  altogether  absent."  * 

"  The  young  female,"  resumes  Dr.  Kellogg,  "who,  up  to 
the  time  of  these  changes,  has  appeared,  comparatively 
speaking,  a  non-sexual  being  in  her  intercourse  with  her 
companions,  playing  in  childlike  innocence  and  unrestrained 
freedom  with  the  opposite  sex  as  with  her  own,  —  ignorant 
and  unconscious  of  the  powers  within  her,  which  are  soon 
to  be  awakened  from  their  slumbers,  — begins,  as  she  now 
approaches  the  verge  of  womanhood,  to  be  animated  with 
feelings  and  desires  to  which  she  was  before  a  complete 
stranger,  and  which  she  regards  with  a  deep  interest  as  the 

*  Dictionary  of  Medicine,  art.  Menstruation,  vol.  ii.  p.  959. 


IN   WOMEN.  85 

forerunners  of  something,  she  scarcely  knows  what,  which 
she  feels  inclined  to  cherish,  yet  shrinks  from,  as  though  she 
knew  not  whether  they  were  of  good  or  evil  omen. 

"  In  her  intercourse  with  her  former  playmates  of  the 
opposite  sex,  there  appears  gradually  to  have  dawned  upon 
her  an  interesting  shyness  and  maidenly  reserve.  Ex- 
pressions which  before  conveyed  no  meaning  to  her  pure 
mind,  and  which  even  now  are  but  partially  understood,  are 
yet  sufficiently  so  to  tinge  her  cheek,  and  cause  her  to  shrink 
back  instinctively,  as  from  some  foul  and  pestilential  pres- 
ence. Her  likes  and  dislikes  are  stronger,  and  rendered 
more  apparent  to  those  around  her.  In  short,  the  physical 
changes  brought  about  in  a  limited  period  of  time  in  the 
sexual  system  have  wrought  a  complete  change  in  the  men- 
tal and  moral  character  of  the  young  girl,  and  this  period 
of  transition  terminates  in  that  of  complete  womanhood, 
with  all  its  desires  and  its  aspirations,  its  hopes  and  its 
fears,  its  joys  and  its  sorrows. 

"But  it  is  in  connection  with  the  various  diseases  inci- 
dent to  the  female  generative  system  that  we  are  to  look 
for  the  more  curious  illustrations  of  this  cerebral  sympathy. 
The  abnormal  mental  state  of  many  patients  laboring  under 
hysteria,  menorrhagia,  dysmenorrhcea,  amenorrhoea,  and 
the  aifections  intimately  associated  with  uterine  derange- 
ment, has  long  been  observed  by  medical  men."  "In  at 
least  three  cases  out  of  four,"  says  Dr.  Francis,  "  I  have  found 
hysteria  associated  with  uterine  derangement,  and  the  resto- 
ration of  the  menstrual  function  to  its  healthy  state  has 
proved  the  precursor  of  the  removal  of  the  hysterical  annoy- 
ance." Hysteria,  again,  may  manifest  itself  chiefly  by  dis- 
order of  the  mental  faculties,  and  the  moral  feelings  and 
emotions.  "The  mental  affections,"  observes  Dr.  Copland, 
"  connected  with  hysteria  may  be  referred,  i.  to  certain 
states  of  monomania,  among  which  excited  desire,  amount- 
ing in  some  cases  to  nymphomania,  maybe  enumerated; 
2.  to  ecstasies  and  mental  excitement,  in  some  cases  of  a 
religious  nature,  in  others  of  different  descriptions;  3.  to  a 
state  of  somnambulism  ;  4.  to  a  form  of  delirium,  generally 


86  REFLEX    INSANITY 

of  a  lively  character,  with  which  various  hysterical  symp- 
toms are  often  conjoined  ;  5.  to  various  delusions,  generally 
of  a  hypochondriacal  kind,  to  which  the  patient  may  become 
subject  or  even  the  victim,  owing  to  the  indulgence  she  may 
meet  with  from  imprudently  kind  relatives;  and,  6.  to  a 
desire  to  feign  various  diseases,  sometimes  of  an  anomalous 
or  singular  form."  ♦ 

The  subjoined  remarks  of  this  same  acute  and  phil- 
osophical physician  are  so  apposite  that  we  cannot 
resist  the  temptation  to  transcribe  them  in  this  con- 
nection. 

"  Hysterical  females,"  says  he,  "  are  not  merely  capricious 
or  whimsical,  but  they  often  become  enthusiastic  for  a  timft 
in  the  pursuit  of  an  object,  or  in  cherishing  an  emotion  by 
which  they  have  been  excited.  In  many  such  cases  the  ner- 
vous excitement  and  vascular  turgescence  of  the  uterine  or- 
gans determine  the  character  of  the  mental  disorder,  elevat- 
ing certain  of  the  moral  sentiments,  or  of  the  intellectual 
manifestations,  to  a  state  of  extravagance,  passing  in  some 
instances  into  delusion  or  monomania.  Many  cases  of 
puerperal  mania  are  merely  extremes  of  the  hysterical  dis- 
order of  the  moral  and  intellectual  powers  or  states  of  the 
mind.  All  these  more  extreme  forms  of  mental  affection 
are  observed  only  where,  in  connection  with  much  local  or 
uterine  irritation,  there  is  great  deficiency  of  nervous  energy 
generally,  and  of  mental  power  in  particular;  or  where, 
with  such  deficiency,  there  has  been  much  injudicious  cul- 
ture or  perversion,  or  improper  excitement  of  the  imagina- 
tion. Females  sometimes  become  passionately  attached  to 
an  object,  and  this  passion  may  advance  even  to  nympho- 
mania or  monomania. 

"  The  hypochondriacal  feelings,  the  desire  to  deceive,  or  to 
simulate  various  diseases,  or  the  delusions  which  sometimes 
possess  the  minds  of  hysterical  females,  may  be  classed  with 
the  foregoing,  as  requiring  a  similar  plan  of  treatment.    In 

*  Loc.  dtat,  voL  u.  p.  321. 


IN    WOMEN.  87 

all  of  them  the  intentions  of  cure  are  to  remove  irritation 
or  vascular  turgescence  of  the  uterine  organs;  to  improve 
the  general  health ;  to  strengthen  the  nervous  system ;  to 
calm  the  imagination;  and  to  guide  the  moral  impulses  of 
the  patient.  The  most  efficient,  however,  of  these  means 
are  not  likely  to  be  adopted  by  the  patient.  Few  will  resort 
daily  to  the  shower-bath,  or  even  occasionally  to  terebinthi- 
nate  enemata,  or  submit  to  a  course  of  tonics,  or  to  a  suita- 
ble regimen,  &c.,  while  they  believe  their  health  but  little 
aftected.  Even  when  the  hysterical  disorder  is  of  a  very 
painful  kind,  the  variability  or  capricious  state  of  the  pa- 
tient's mind  leads  her  to  run  from  one  physician  to  another, 
before  opportunity  of  administering  aid  is  afforded  to  any. 
At  last,  the  most  notorious  charlatans,  particularly  those 
who  excite  the  body  through  the  mind  or  the  mind  through 
the  body,  the  animal  magnetizers,  the  homoeopathists,  the 
St.  John  Longs  of  rubbing  celebrity,  and  the  Campbells  of 
celestial-bed  notoriety,  fix  her  attention.  At  such  medical 
bagnios  there  is  something  promising  gratification  as  well 
as  excitement,  and  at  such  places  hysterical  as  well  as  hypo- 
chondriacal patients  '  most  do  congregate.'  * 

"  When  we  pass  from  the  consideration  of  the  influence 
of  the  reproductive  system  upon  the  cerebral,  to  take  a  view 
of  the  influence  of  the  latter  upon  the  former,  we  enter  upon 
an  inquiry  possessing  as  profound  an  interest  as  any  in  the 
whole  domain  of  science ;  and  here,  again,  as  before,  we 
have  to  look  to  the  female  economy  for  the  most  interesting 
facts  and  phenomena  illustrative  of  this  mysterious  and  in- 
explicable sympathy.  The  results  of  this  influence,  if  we 
allow  ourselves  to  believe  the  statements  and  receive  as  evi- 
dence what  is  brought  forward  as  fact  in  illustration  of  it, 
are,  indeed,  sometimes  most  extraordinary;  and  the  unmis- 
takable evidence  of  this,  which  is  from  time  to  time  present- 
ed to  the  medical  observer,  is  sometimes  so  curious  as  to 
make  him  pause  before  rejecting,  as  the  workings  of  a  mor- 
bid imagination,  the  statements  which  are  sometimes  made 
by  intelligent  females,  whose  veracity  we   cannot   doubt, 

•  Copland,  loc.  citaL,  voL  ii.  p.  337. 


^  REFLEX    INSANITY 

and  whose  motives  for  deceiving  us  we  are  unable  to  dis- 
cover. 

"  There  are  few  physicians  of  experience  who  will  not  be 
able  to  call  to  mind  some  extraordinary  statements  made  to 
them  by  females  in  reference  to  this  sympathy,  which  at  the 
time,  no  doubt,  merely  called  forth  a  smile  of  incredulity  or 
surprise  at  what  was  then  regarded  as  the  result  of  supersti- 
tion, or  of  a  morbid  imagination,  but  which,  in  after  hours, 
has  been  seized  upon  as  food  for  reflection."  ♦ 

To  these  remarks  of  Dr.  Kellogg,  there  would  be 
little  need  of  adding,  had  they  but  been  practically 
accepted  and  acted  upon.  Such,  however,  has  not 
been  the  case.  Nearly  ten  years  have  elapsed  since 
their  publication,  and,  as  yet,  in  the  reports  of  no 
asylum  do  we  find  a  change,  either  in  the  method  of 
tabulating  cases,  of  specifying  causes,  or  of  treatment. 
The  organ  of  psychologists  in  this  country,  the  Amer- 
ican Journal  of  Insanity,  generally  so  ably  conducted, 
in  which  Dr.  Kellogg's  paper  appeared,  and  which 
emanates  fr-om  the  asylum  with  which  he  is  connect- 
ed, still  ignores  the  conclusions  he  had  advanced,  as 
shown  alike  in  its  editorial  papers  and  in  its  com- 
ments, or  absence  of  comments,  upon  those  by  others, 
admitted  to  its  pages.  I  need  adduce  but  a  single 
instance.  Sir  William  Hamilton,  in  his  celebrated 
work  upon  metaphysics,  makes  use  of  the  following 
language :  "  A  fact  striking  in  itself,"  he  says,  "  and 
not  without  significance  in  relation  to  the  present  in- 
quiry, is  this,  that  these  intruders  "  (parasitic  animals 

*  American  Journal  of  Insanity,  April,  1856,  pp.  306-ia 


IN   WOMEN.  S9 

of  various  kinds,  worms  in  every  loathsome  diversity, 
reptiles  armed  with  fangs,  crawlers  of  a  hundred  feet, 
&c.,  &c.),  "  infest  the  (frontal)  sinuses  of  women." 
This  statement,  so  strange  and  astonishing  as  regards 
its  application  to  most  women,  sane  or  insane,  was 
reproduced  in  the  Journal  referred  to,  by  a  reviewer 
of  Hamilton,  but  ten  years  ago,  without  a  word  of 
contradiction.* 

While  a  single  fact  like  the  above  can  take  place,  a 
single  assertion  of  that  character  pass  unchallenged 
alike  by  the  Journal  and  the  profession  at  large,  it 
cannot  be  argued  either  that  the  conclusions  presented 
in  this  report  are  generally  known  and  acted  upon,  or 
that  the  investigation  is  one  without  a  very  plain  and 
practical  end. 

The  notion  that  her  sex  plays  an  important  part  in 
the  causation  of  insanity  in  women,  is  by  no  means  a 
modern  one.  Like  many  of  the  most  valuable  theo- 
ries of  medicine,  it  dates  back  to  remotest  antiquity. 

Aretaeus,  of  Cappadocia,  held  that  a  frequent  cause 
of  mania  was  to  be  found  in  suppression  of  the  men- 
ses, or  difficulty  in  their  establishment  in  young  wo- 
men, who  needed  only  this  condition  of  marriage.* 

Soranus  enumerates,  among  other  causes,  the  long 
continued  use  of  medicines  that  excite  the  genital  or- 
gans in  women,  and  the  suppression  of  their  periodical 

•  American  Journal  of  Insanity,  June,  i860,  p.  255. 

t  Tr^lat :  Recherches  Historiques  sur  la  Folia,  1839,  p.  tz. 


9©  REFLEX   INSANITY 

discharge.*  Before  the  expedition  of  the  Argonauts, 
and  before  Hippocrates,  it  is  said  that  the  daughters 
of  King  PrcEtus,  whose  savage  lowingsf  remind  one 
of  certain  historical  and  modern  epidemics  of  insanity 
complicated  with  hysteria,  were  cured  by  means  of 
hellebore,  which  was  then  supposed  to  exercise  a 
peculiar  influence  upon  the  uterus.J  The  theory  of 
pelvic  causation,  like  all  others,  however  good,  did 
not  even  at  that  early  period  escape  criticism.  Coe- 
lius  Aurelianus,  for  instance,  affirmed  that  women 
were  less  subject  to  insanity  than  men ;  but  his  re- 
viewers and  admirers  of  more  modern  times,  and  at 
the  present  day,  however  they  undertake  to  explain 
the  fact,  yet  think  that  he  was  mistaken.  This  state- 
ment is  true  of  Esquirol,  Copland,  Brown,  and  many 
others,  some  of  whom  I  shall  hereafter  quote.  Thus, 
Dr.  Haslam  has  averred,  speaking  of  England,  that 
*'  in  our  own  climate,  women  are  more  frequently  af- 
flicted with  insanity  than  men." 

On  the  other  hand,  to  bring  this  disputed  question 
down  to  the  present  moment.  Dr.  Thurnam,  in  his 
paper  upon  the  relative  liability  of  the  two  sexes  to 
insanity,  expresses  himself  as  follows  :  — 

"  Having  thus  shown  that  in  the  principal  hospitals  for 
the  insane  in  these  kingdoms,  the  proportion  of  men  admit- 
ted is  nearly  always  higher,  and,  in  many  Instances,  much 

•  Morel :  Trait*  des  Maladies  Mentales,  p.  4. 

t  "  Proetides  implerunt  falsis  mugitibus  agros."    Ibid.,  p.  19. 

t  Griffith:  Medical  BoUny.p.  86. 


IN   WOMEN.  91 

higher  than  that  of  women,  and  as  we  know  that  the  pro- 
portion of  men  in  the  general  population,  particularly  at 
those  ages  when  insanity  most  usually  occurs,  is  decidedlj' 
less  than  that  of  women,  we  can  have  no  ground  for  doubt- 
ing that  men  are  actually  more  liable  to  disorders  of  the 
mind  than  women."* 

Dr.  Bucknill,  also,  is  of  opinion  that  it  is  clearly 
proved  that,  in  general,  fewer  women  become  insane 
than  men.f 

Upon  this  side  the  water,  this  question  of  the  com- 
parative liability  of  males  and  females  to  insanity, 
has  been  carefully  investigated  by  Dr.  Edward  Jarvis, 
of  Dorchester,  in  a  paper  published  in  the  Journal 
of  Insanity  several  years  since.  He  also  has  arrived 
at  the  conclusion  that  males  are  somewhat  more  liable 
to  insanity  than  females. 

There  are,  it  will  be  perceived,  several  very  differ- 
ent questions  here  involved,  as  the  following :  — 

1.  Do  more  women,  abstractly,  than  men,  become 
insane  ? 

2.  Do  more  women  become  insane,  in  proportion 
to  the  number  of  each  sex  existing  in  a  given  hospi- 
tal, city,  state,  or  country? 

3.  Do  more  women  than  men  become  insane  from 
sexual  causes? 

The  latter  question,  it  will  be  perceived,  is  the  only 
one  that  concerns  us  in  the  present  inquiry.  It  is 
to  the  two  former,  however,  that  attention  has  gen- 

*  Quarterly  Journal  of  the  Statistical  Society  of  London,  December,  1844. 
t  Loc.  cit.,  p.  245. 


92  REFLEX    INSANITY 

erally  been  given.  As  the  attempt  at  their  solution, 
though  this  must  evidently  be  almost  impossible,  has 
been  made,  I  will  give  it  a  moment's  notice.  Dr. 
Bucknill  has  admitted  that  there  are  many  points  that 
observers  have  practically  lost  sight  of. 

"  SuflScient  care,"  he  says,  '*  does  not  appear  to  have  been 
taken  to  ascertain  the  relative  number  of  males  and  females 
in  the  general  population,  a  point  obviously  necessarj'  to 
determine,  before  any  just  conclusion  can  be  drawn  as  to  the 
relative  liability  of  the  sexes  to  insanity.  Writers  upon  the 
subject  have  found  the  existing  number  of  female  lunatics 
greater  than  that  of  the  males,  and  hence,  have  arrived  at 
the  conclusion  that  the  female  sex  is  more  subject  to  insan- 
ity than  the  male.  Dr.  Thurnam.  however,  has  pointed  out 
this  source  of  fallacy,  as  well  as  that  which  arises  from  the 
fact  that  the  mortality  of  insane  men  exceeds  that  of  insane 
women  by  fifty  per  cent.  Hence  it  is  obvious  that  Esquirol 
erred,  in  comparing  the  existing  instead  of  the  occurring 
cases  of  insanity  in  the  male  and  female  sexes.  If.  in  our 
asylums,  women  live  longer  than  men,  they  will  of  course 
proportionately  accumulate." 

"  In  order  that  the  comparison  of  the  occurring  cases  be 
a  strictly  accurate  one,"  observes  Thurnam,  "  the  propor- 
tions of  the  two  sexes  at  the  several  ages,  attacked  with 
insanity  for  the  first  time,  should  be  compared  with  the  pro- 
portions in  which  the  two  sexes  at  the  same  ages  exist  in  the 
community  in  which  such  cases  occur.  The  nearest  approx- 
imation to  this  method  which  we  have  the  means  of  employ- 
ing is,  by  assuming  that  the  proportions  of  men  and  women 
admitted  into  public  institutions  during  extensive  periods 
represent —  as,  on  the  whole,  they  probably  do  represent  — 
the  cases  which  occur  for  the  first  time." 

"  From  an  examination  of  a  table  prepared  by  this  writer, 
it  was  ascertained  that,  in  twenty-four  of  the  thirty-two  asy- 
lums, which  it  comprises,  there  had  been  a  decided  excess 
of  men  in  the  numbers  admitted.    In  many  British  asylums, 


IN    WOMEN.  93 

the  excess  amounts  to  twentj-five,  thirty,  and  even  forty  per 
cent.,  and,  in  the  whole  number  of  thirty- two  asylums,  there 
is  an  average  excess  on  the  side  of  the  male  sex  of  thirteen 
and  seven  one  hundredths  per  cent.  In  the  nine  English 
county  asylums  contained  in  the  table,  the  excess  amounts 
to  twelve  per  cent. 

"  From  the  same  tables,  it  appears  that,  in  the  asylums  of 
the  metropolis,  the  proportion  of  females  admitted  is  much 
greater  than  in  the  provinces.  This  appears  to  be  in  part 
accounted  for  by  there  being  a  considerable  excess  per  cent, 
(thirteen  per  cent,  at  all  ages,  and  nineteen  per  cent,  at  all 
ages  above  twenty)  of  women  over  men  in  the  metropolis.* 
Hence,  the  experience  of  Bethlem  and  St.  Luke's  led  Dr. 
Webster  to  the  conclusion,  that  no  doubt  can  exist  regarding 
the  greater  frequency  of  mental  alienation  among  females 
than  males.  Dr.  Thurnam  appears  to  regard  it  as  probable, 
that  the  statistics  of  insanity  in  France  resemble  in  this  par- 
ticular those  of  London,  although,  as  has  been  pointed  out, 
the  method  of  inquiry  adopted  by  Esquirol  was  vicious. 

"  Jarvis  has  shown,"  continues  Bucknill,  "  that  the  causes 
of  insanity  which  act  upon  males  are  more  extensive  than 
those  which  act  upon  females,  and  has  added  that  the  above 
statement,  in  regard  to  the  liability  of  the  sexes,  must  vary 
with  different  nations,  different  periods  of  the  world,  and 
different  habits  of  the  people. 

"  It  would  be  difficult  to  establish  that  the  female  sex  is 
intrinsically  less  susceptible  to  the  causes  of  insanity  than 
the  male,  since  the  former  is  less  exposed  to  those  causes 
than  the  latter;  at  least,  to  establish  the  greater  intrinsic 
liability  of  females,  it  must  be  shown  that  they  are  exposed 
to  the  predisposing  and  exciting  causes  of  insanity  to  as 
great  an  extent  as  males."  f 

*  On  the  other  hand,  in  some  parts  of  this  country,  in  Massachusetts  for  in- 
stance, the  excess  of  women  is  much  greater  than  in  London,  being  estimated 
of  late  at  fifty  per  cent.,  or  even  higher  ;  and  yet  there  seems  to  be  no  proportion- 
ate excess  of  famale  admissions  at  asylums. 

t  Loc.  cit.;  p.  245.  This  "last  sentence  is  expressive  only  of  Bucknill's  opinion; 
I  think  it  will  appear  that  women  are  exposed  constantly  to  the  action  of  these 
causes  to  a  greater  extent  than  are  men. 


94  REFLEX    INSAXITY 

In  this  connection,  as  in  many  others,  it  must  not 
be  forgotten  that  the  statistics  of  the  insane,  whether 
derived  from  hospitals  or  from  the  general  popula- 
tion, are  very  liable  to  be  faulty  or  to  give  rise  to 
erroneous  conclusions.  I  shall  subsequently  give 
evidence  to  this  effect,  and  the  opinions  of  Luther  V. 
Bell  and  others  ;  here  merely  asking,  — 

"  What  can  be  the  value  of  medical  statistics  in  any  dis- 
ease, under  which  sixty  per  cent,  of  the  entire  cases  must  be 
left  unaccounted  for?  Probably  too,  not  five  out  of  twenty 
of  the  assigned  causes  are  justly  chargeable  with  the  mental 
disease  ascribed  to  them."  * 

In  the  present  instance,  writers  seem  to  have  lost 
sight  of  the  facts  that  in  almost  all  countries  more 
males  than  females  are  born  ;  that  this  percentage  of 
excess,  which  would  be  veiy  much  greater  were  all 
the  males  that  are  conceived  born  living,  is  to  a  cer- 
tain extent  kept  down  by  the  number  of  boys  who 
die  in  infancy  and  during  childhood  in  consequence 
of  various  affections  to  which  the  comparatively 
larger  size  of  the  head  in  the  male  foetus  has  given 
rise,  from  the  greatei  pressure  to  which  it  was  neces- 
sarily subjected  during  parturition  ;  f  and  that  in  this 


*  Workman :  Report  of  the  Provincial  Lunatic  Asylum  at  Toronto,  1863,  p.  5. 
t  Dr.  Simpson,  in  his  memoirs  upon  the  sex  of  the  child  as  a  cause  of  diffi- 
culty and  danger  in  human  parturition,  has  shown  conclusively,  that  — 

1.  Of  the  mothers  that  die  under  parturition  and  its  immediate  consequences, 
a  much  greater  portion  have  given  birth  to  male  than  female  children. 

2.  Among  labors  presenting  morbid  complications  and  difficulties,  the  child  is 
much  oftener  male  than  female. 

3.  Among  the  children  of  the  mothers  that  die  from  labor  or  its  consequences, 


IN   WOMEN.  95 

same  excess  of  cerebral  compression,  is  undoubtedly 
to  be  found  an  efficient  cause  of  insanity  in  man  in 
after  life.  This  point  does  not  appear  to  have  been 
before  observed.  It  has  also  been  forgotten  that 
males  everywhere,  save  perhaps  in  the  most  crowded 
cities,  are  much  more  likely  than  women  to  be  carried 
from  home  and  the  care  of  relatives  to  the  seclusion 
of  an  asylum  ;  that  in  women,  the  attacks  are  more 
seldom  persistent,  more  frequently  intermittent,  par- 
oxysmal, periodical,  and  therefore  more  likely  to  be 
endured  by  friends,  and  to  be  more  constantly 
looked  upon  as  merely  hysterical,  nervous  or  feigned, 
while  no  one  at  all  familiar  with  the  subject 
would  undertake  to  prove,  as  Bucknill  has  supposed 


a  larger  proportion  of  those  that  are  still-born  are  male  than  female :  and,  on  the 
contrary,  of  those  that  are  bom  alive  a  larger  proportion  are  female  than  male. 

4.  Of  still-bom  children,  a  larger  proportion  are  male  than  female. 

5.  Of  the  children  that  die  during  the  actual  progress  of  parturition,  the  num- 
ber of  males  is  much  greater  than  the  number  of  females. 

6.  Of  the  children  bom  alive,  more  males  than  females  are  seen  to  suffer 
from  the  morbid  states  and  injuries  resulting  from  parturition. 

7.  More  male  than  female  children  die  in  the  earliest  period  of  infancy,  and 
the  disproportion  between  the  mortality  of  the  two  sexes  gradually  diminishes 
from  birth  onwards,  until  some  time  subsequently. 

8.  Of  the  children  that  die  in  utero  and  before  the  commencement  of  labor, 
as  large  a  proportion  are  females  as  males. 

9.  In  laborious  labor  with  the  head  presenting,  in  proportion  as  the  order  of 
labor  rises  in  difficulty,  the  amount  of  male  births  rises  in  number. 

10.  Of  the  morbid  accidents  that  are  liable  to  happen  in  connection  with  the 
third  stage  of  labor,  after  the  head  has  passed  the  brim  of  the  pelvis,  as  many 
take  place  with  female  as  with  male  births. 

11.  More  dangers  and  deaths  occur  both  to  mothers  and  children  in  first  than 
in  subsequent  labors. 

12.  The  average  duration  of  labor  is  longer  with  male  than  with  female  (iiil« 
dren.  —  Obstetric  Works.  Edited  by  Drs.  Priestley  and  H.  R.  Storer.  Edin 
burgh  edition,  i.  p.  394. 


96  REFLEX   INSANITY 

possible,  that  women  are  intrinsically  less  susceptible 
to  the  same  causes  of  insanity  that  affect  men.  On 
the  contrary,  we  would  claim  that  these  very  produc- 
tive and  efficient  causes  do  act,  so  far  as  women  are 
exposed  to  them,  and  a  thousand-fold  more  besides. 

It  has  been  supposed  that  moral  influences,  and 
those  purely  mental  in  their  character,  have  exercised 
an  important  part  in  the  causation  of  insanity.  In 
the  case  of  women,  in  the  absence  of  a  predisposition 
to  insanity  by  inheritance,  I  believe  that  these  moral 
causes  seldom  efficiently  act  unless  in  the  presence  of 
physical  disturbance. 

Be  this  as  it  may,  much  attention  has  been  paid  by 
psychologists  to  the  classification  of  these  alleged 
moral  excitations.  Thus  Tuke,  from  an  analysis  of 
some  thirty  thousand  cases,  admitted  into  a  large 
number  of  asylums  in  England,  France,  and  Amer- 
ica, found  that  among  them  domestic  troubles  or 
grief  stand  first  in  the  list  in  every  instance  ;  next  in 
order,  religious  anxiety  or  excitement ;  then  disap- 
pointed affections,  political  and  other  excitements, 
fear  and  fright ;  and  lastly,  excessive  study  and 
wounded  feelings,  as  impaired  self-love,  etc.*  There 
is,  of  course,  no  doubt  that  men  are  more  exposed 
tlian  women  to  political  excitement  and  the  harassing 
anxieties  of  business ;  but  these  we  find  Esquirol 
considering   as    more   than   counterbalanced   by  the 

•  Manual,  p.  as8. 


IN    WOMEN.  97 

vices  of  female  education  ;  the  preference  given  to 
acquirements  purely  ornamental  ;  the  reading  of  ro- 
mances, from  which  arises  a  precocious  activity  of 
the  intellect  and  premature  desires,  together  with 
ideas  of  an  imaginary  excellence  that  can  never  be 
realized  ;  the  frequenting  of  plays  and  society  ;  the 
abuse  of  music  and  the  want  of  occupation — these, 
he  thinks,  are  causes  sufficient  to  make  insanity  most 
frequent  among  women.* 

Dr.  Conolly,  of  the  Hanwell  Asylum,  but  reiterates 
this  opinion  when  he  says  that  — 

"All  who  have  peculiar  opportunities  of  ascertaining  the 
menial  habits  of  insane  persons  of  the  educated  classes  well 
know  that,  with  some  exceptions,  their  previous  studies  and 
pursuits  appear  to  have  been  superficial  and  desultory,  and 
often  frivolous;  the  condition  of  the  female  mind,  especially 
of  the  minds  of  those  who  are  to  be  the  mothers  of  another 
generation,  is,  even  in  the  highest  classes,  too  often  more 
deplorable  still.  Not  only  is  it  most  rare  to  find  them  famil- 
iar with  the  best  authors  of  their  own  country,  but  most 
common  to  find  that  they  have  never  read  a  really  good 
author,  either  in  their  own  or  in  any  other  language;  and 
that  the  few  accomplishments  possessed  by  them  have  been 
taught  for  display  in  society,  and  not  for  solace  in  quieter 
hours.  All  this  has  been  said  before,  and  often,  and  in 
vain.  But  there  is  a  frequent  perversion  of  intellectual  exer- 
cise more  fatal  than  its  omission,  which  fills  asylums  with 
lady  patients,  terrified  by  metaphysical  translations,  and 
bewildered  by  religious  romances,  and  who  have  lost  all 
custom  of  healthful  exertion  of  body  or  mind,  all  love  of 
natural  objects,  all  interest  in  things  most  largely  influen- 
cing ihe  happiness  of  mankind.     All  the  higher  pleasures 

*  Mental  Maladies,  p.  235. 


98  REFLEX   INSANITY 

of  human  beings  have  always  been  unknown  to  these  pa- 
tients. Minds  so  feeble,  or  so  spoiled,  are  unfit  for  the  or- 
dinary emergencies  of  a  checkered  life.  Every  stronger 
shock  quite  discomposes  them.  These  evils  have  generally 
taken  deep  root  before  the  patient's  manifest  want  of  rea- 
sonable control  induces  a  resort  to  an  asylum ;  but  a  large 
portion  of  the  moral  treatment  resorted  to  in  asylums  con- 
sists in  the  discouragement  of  the  evil  habits  of  mind  into 
which  such  frivolous  and  unhappy  beings  have  fallen.  Ex- 
ercise in  the  open  air;  customary  and  general  activity; 
regular  hours;  a  moderate  attention  to  music  and  other 
accomplishments,  instead  of  an  extravagant  devotion  of 
time  to  such  excitements;  protection  from  fanatical  exhor- 
tations ;  and  the  substitution  of  sensible  books  for  the 
worthless  tracts  and  volumes  with  which  their  well-meaning 
friends  have  generally  loaded  their  boxes,  and  which  are 
thenceforth  locked  up  as  so  much  mental  poison,  contribute 
largely  to  the  patient's  advance  towards  rationality.  The 
same  kind  of  care  might,  in  many  cases,  have  preserved  the 
mind  from  derangement;  but  the  attention  of  parents  and 
teachers  is  seldom  directed  to  the  important  object  of  the 
prevention  of  insanity."  * 

These  and  many  others  that  might  be  mentioned, 
are  undoubtedly  predisposing  causes  of  insanity  in 
women.     Asks  Esquirol,  — 

"Are  not  the  extreme  susceptibility  and  sedentary  life  of 
women,  their  peculiarities  even,  the  predisposing  cause  of 
this  malady?  The  numerous  passions  which  among  them 
are  so  active;  religion,  which  is  a  veritable  passion  with 
many  when  love  does  not  exclusively  occupy  their  heart  and 
mind,  jealousy,  fear,  do  not  these  act  more  energetically  on 
the  minds  of  women  than  men?  As,  said  Zimmerman, 
'  insanity  comes  often  to  girls  from  love,  to  women  from 
jealousy,  while  from  pride  to  men.'     Moreover,"  continues 

•  Treatment  of  the  Insane,  p.  i6a 


IN   WOMEN.  99 

Esquirol,  "women  yield  to  the  causes  of  insanity  proper  to 
the  sex;  physical  causes  acting  more  frequently  upon  them 
than  upon  men.  Are  not  women  under  the  control  of  influ- 
ences to  which  men  are  strangers ;  such  as  menstruation, 
pregnancy,  confinement,  and  nursing?"* 

That  healthful  though  continued  mental  excitement 
may  prevent  the  tasdium  vitae  which  over-indulgence 
in  the  dissipations  of  society  so  often  brings  to  women 
is  no  paradox,  and  we  should,  therefore,  have  no  rea- 
son for  wonder,  if  there  had  in  reality  been  "  a  de- 
crease of  cases  of  insanity  occurring  in  women  since 
the  present  war  commenced,  from  the  various  chari- 
table and  benevolent  operations  which  have  so  largely 
excited  their  sympathies  and  received  their  support," 
although,  upon  the  other  hand,  there  would  seem  to 
have  been  at  least  a  counterbalancing  number  of 
shocks  from  sudden  bereavement  and  fright. 

That  the  predisposing  or  proximate  causes,  whether 
moral,  mental,  or  not,  —  and  the  physical  or  ultimate 
causes  rarely  act  alone,  —  is  no  proof  of  the  non-exist- 
ence of  either.  They  unite  and  become  complicated 
in  many  cases  where  they  produce  insanity.  A  fright 
occasions  the  suppression  of  the  menses,  and  this 
becomes  the  cause  of  mania,  which  ceases  with  the 
return  of  the  menstrual  evacuation.  A  woman  dur- 
ing her  confinement  experiences  a  severe  disappoint- 
ment ;  the  lochia  are  suppressed,  and  an  eruption  of 
mania  takes  place.     We  may  with  truth  affirm  that 

*  Mental  Maladies,  p.  211. 


lOO  REFLEX    INSANITY 

insanity  in    women   rarely  takes   place  without  the 
concurrence  of  both  physical  and  moral  causes.* 

It  is  well  known  that  much  of  the  insanity  of  women 
has  been  attributed,  both  in  asylum  reports  and  else- 
where, to  previous  general  ill  health,  as  owing,  in 
some  instances,  to  the  effects  of  climate,  hard  work, 
etc.  Upon  this  point  I  will  subjoin  a  few  remarks 
that  have  been  communicated  to  me  by  my  colleague, 
Dr.  Patterson,  of  the  Iowa  Asylum. 

*'  It  will  be  seen  that  among  the  assigned  causes,  '  ill 
health'  of  various  kinds  is  most  prominent.  It  will  seem 
strange  that  among  the  rural  population  of  Iowa,  away  from 
the  excitements,  temptations,  excesses,  and  poverty  of  large 
cities,  alike  remote  from  the  malarious  fevers  of  the  South, 
and  the  pinching  cold  of  the  North,  while  quietly  engaged 
in  the  peaceful  pursuits  of  agriculture,  any  considerable 
number  of  our  people  should  ever  become  insane.  And  yet 
such  is  the  fact.  Many  of  them,  especially  the  wives  and 
daughters  of  farmers,  become  insane.  Probably  three  fourths 
of  the  adult  people  of  Iowa  are  connected  with  agricultural 
pursuits. 

^^  A  vast  majority  of  all  cases  of  insanity  arise  from  causes 
and  circumstances  vjhich  depress  or  exhaust  the  nervous 
power.  Grief,  domestic  unhappiness,  disappointed  affec- 
tion, the  puerperal  state,  perplexities  in  business,  all  tend  to 
depress,  and,  if  long  continued,  to  exhaust  the  vital  force, 
and  are  therefore  prolific  causes  of  insanity. 

*'  The  farmers  of  Iowa  have  not  yet  learned  how  to  live 
comfortably.  Their  dwellings  are  badly  constructed,  often 
in  low,  damp,  poorly-drained  locations,  with  either  no  venti- 
lation, or  too  much.  They  are  badly  warmed  by  direct 
radiation  of  heated  iron,  so  that  the  process  of  partial  roast- 
ing and  freezing  is  at  once  experienced  by  the  same  person 

*  Mental  Maladies,  p.  382. 


IN   WOMEN.  lOI 

Their  surroundings  are  too  often  unpropitious,  their  physical 
comforts  and  social  enjoyments  too  much  neglected.  In 
inclement  seasons,  amid  exposures  to  cold  and  rain,  their 
bodies  probably  receive  less  care  and  protection  than  those 
of  any  other  class.  With  abundant  supplies  at  command, 
their  diet  is  too  limited  in  variety,  often  unskilfully  pre- 
pared, and  the  whole  science  of  gastronomy  set  at  nought. 
The  laboratory,  in  which  are  manufactured  the  life  blood 
and  the  vital  forces,  is  too  often  lumbered  with  ill-assorted, 
indigestible,  badly-cooked  food. 

"The  wives  and  daughters  of  farmers,  during  inclement 
seasons,  have  fewer  comforts  connected  with  out  of  doors 
life,  and  less  adequate  protection  from  cold  and  humid  air, 
than  the  women  who  live  in  our  towns  and  cities,  and  it  is 
probable,  taking  prairie  farm  life,  with  all  of  its  surround- 
ings, as  it  exists  in  Iowa,  that  the  average  standard  of  the 
vital  force  in  those  who  live  upon  farms,  is  beloAv  that  of 
those  who  live  in  the  towns  and  cities.  It  must  not,  how- 
ever, be  inferred  from  these  suggestions  that  the  noble  and 
pleasing  pursuits  of  agriculture  favor  the  production  of  in- 
sanity. The  errors  of  living,  and  the  discomforts  alluded 
to,  are  not  necessarily  connected  with,  and  certainly  not 
limited  to  farm  life. 

*'  Much  of  our  insanity  results  from  our  ignorance  or  dis- 
regard of  the  laws  of  animal  life.  Much  of  it  might  be 
avoided  by  the  exercise  of  proper  care  and  good  judgment 
in  forming  alliances,  and  in  the  care  of  our  bodies,  which 
are  so  'fearfully  and  wonderfully  made;'  by  ruling  the 
passions  and  appetites ;  by  lives  of  prudence ;  by  modera- 
ting the  extravagant  expectations  of  this  life;  by  using  in- 
nocent recreations  and  the  bounties  of  a  kind  Providence  as 
not  abusing  them ;  by  regular  hours  and  favoring  circum- 
stances for  refreshing  sleep  ;  by  well-regulated  households  ; 
by  an  abiding  religious  faith,  and  by  the  avoidance  of  iliose 
indulgences  and  habits  of  life  -which  favor  a  deterioration 
of  the  blood,  depress  and  exhaust  the  nervous  power,  and 
break  doivn  the  defences  which  Nature  has  set  up  for  our 
■protection.'"'' 


I02  REFLEX    INSANITY 

There  can  be  no  doubt  that  influences,  such  as  have 
been  above  described,  do,  in  many  instances,  exert  a 
powerful  influence  upon  the  nervous  system  in  wo- 
men, especially  if  accompanied  by  disturbance  of  the 
pelvic  organs,  which,  indeed,  tliey  are  so  likely  to 
occasion. 

The  point  to  which  we  have  now  so  naturally  been 
brought,  —  the  physical  causes  of  insanity  peculiar 
to  women,  and  their  preponderance  and  efficiency  as 
compared  with  those  of  the  male  sex,  —  is  one  that  is 
allowed  by  many  writers,  but  by  most  of  them  is  either 
forgotten  or  practically  contradicted  in  treatment. 
Thus  Tuke,  in  his  analysis  of  physical  causes,  in  both 
male  and  female,  upon  a  basis  of  many  thousands  of 
cases,  places  first  intemperance,  and  next  epilepsy 
and  disorders  more  or  less  connected  with  the  uterus, 
considering  these  last  as  equally  productive  of  insan- 
ity, and  far  more  frequently  so  than  all  other  diseases, 
or  vicious  indulgences,  or  affections  of  the  head  and 
spine,  whether  idiopathic  or  traumatic*  A  most 
important  allowance  has  here  been  made,  when  it  is 
recollected  that  of  the  causes  above  enumerated,  a 
large  proportion  of  the  intemperance  of  women  ini- 
tiates in  or  is  kept  up  by  alcoholic  stimulants,  for 
the  purpose  of  relieving  functional  or  organic  ute- 
rine disease  ;  that  a  large  proportion  of  the  epilepsy 

•  Loc  cit.,  p.  258. 


IN   WOMEN.  103 

in  women  is  of  uterine  causation,  and  that  a  large 
proportion  of  the  vicious  indulgences  of  women, 
especially  those  of  sell-abuse,  are  dependent  upon 
uterine  or  other  local  irritation,  and  so  the  effect  'Ol 
disease. 

1  shall  present  another  admission  to  the  same  effect 
from  the  same  author,  as  it  more  than  corroborates  the 
conclusions  to  which  we  shall  eventually  be  brought. 
He  says,  — 

"  When  we  reflect  on  the  very  large  number  of  cases  of 
insanity  more  or  less  connected  with  functional  or  organic 
disease  of  the  uterus,  and  remember  that  among  barbarous 
nations  these  disorders  are  unquestionably  of  less  frequent 
occurrence  than  in  civilized  society,  we  shall  not  fail  to 
recognize  in  this  difference  one  reason  why  more  mental 
disease  might  be  looked  for  in  the  one  condition  than  in  the 
other.  Parturition  itself,  according  to  the  general  testimony 
of  travellers,  interferes  much  less,  and  for  a  shorter  period, 
with  the  healthy  action  of  the  body  and  mind  among  savage 
nations  than  among  the  luxurious  daughters  of  artificial 
life."  * 

Dr.  Bucknill  says,  — 

*'  There  can  be  no  doubt  that  uterine  disorders  constitute 
one  of  the  most  frequent  remote  causes  of  insanity  with 
which  we  are  acquainted.  If,  therefore,  the  physician  can 
ascertain  that  his  patient  has  suffered,  or  is  suffering  from 
gastric,  hepatic,  intestinal,  or  uterine  disease,  he  will  have 
discovered  a  well-known  and  frequent  cause,  the  existence 
of  which  must  be  allowed  to  exercise  its  due  influence  in 
the  diagnosis." 

"Disordered  states  of  the  abdominal  viscera,"  he  again 
remarks,  "  are  of  such  frequent  occurrence,  that  the  veteran 

*  Loc.  cit.,  p.  57. 


lO^  KEFLEX    INSANITY 

Jacobi  and  some  other  physicians  of  eminence,  have  believed 
that  they  altogether  account  for  the  causation  of  mental  dis- 
ease. We  are  far  from  being  able  to  concur  in  this  narrow 
view  of  the  etiology  of  insanity;  but  no  physician  of  much 
experience  in  this  department  of  medical  science  will  be 
likely  to  deny,  that  disordered  states  of  the  stomach,  the 
intestines,  and  the  liver,  frequently  constitute  the  remote 
causes  of  cerebral  disease."  * 

It  will  be  remembered  that  many  of  the  disordered 
states  of  the  stomach,  the  intestines,  and  the  liver  in 
women  are  directly  dependent  upon  uterine  derange- 
ment, being  either  caused  or  kept  up  by  this. 

We  are  told  by  another  writer,  that  — 

"  The  functions  peculiar  to  the  female  sex,  and  the  natural 
sensitiveness  of  the  nervous  system  in  the  latter,  render 
them  very  liable  to  disturbance  of  the  mind  when  those 
functions  are  irregularly  performed.  From  the  commence- 
ment of  puberty  to  the  approach  of  old  age,  this  source  of 
disordered  nervous  and  mental  action  exists,  and  in  every 
case  of  insanity  occurring  in  females,  the  possibility  of  some 
bodily  functional  derangement  existing  simultaneously  with, 
and,  perhaps,  operating  as  the  exciting  cause  of,  the  mental 
affection,  should  never  be  forgotten.  Amenorrhcea,  dys- 
menorrhoea,  menorrhagia,  pregnancy,  miscarriages,  partu- 
rition, the  puerperal  state,  lactation,  the  cessation  of  the 
menstrual  function,  are  each  occasionally  productive  of 
mental  disorder,  which  can  only  be  cured  by  attention  to 
the  exciting  cause.  This  consequence  of  such  ailments  is 
naturally  rendered  much  more  probable  when  moral  dis- 
turbing causes  are  also  in  action."  f 

The  frequent  coincidence  of  an  uterine  crisis  or 
of  uterine  disease  with  insanity  in  woman,  must  be 

•  Loc.  cit.,  p.  280. 

t  Robinson:  Physical  Causes  of  Mental  Disorders,  p.  115. 


IN   WOMEN.  105 

allowed.  It  has  been  claimed,  however,  that  this  co< 
incidence  is  one  only  of  time  and  not  of  character, 
that  there  exists  between  them  no  relation  of  cause 
and  effect.  By  no  one  has  this  assertion  been  made 
more  succinctly  or  more  emphatically  than  by  the 
present  superintendent  of  the  hospital  at  Northamp- 
ton, and  late  Professor  of  Psychological  Medicine  in 
Berkshire  Medical  College,  Dr.  Pliny  Earle,  whorn  I 
therefore  quote.     He  says,  — 

"  It  is  well  known  by  persons  who  have  much  experience 
in  insanity,  that  in  females  there  is  no  constant  relationship 
between  the  pathological  mental  condition  and  the  mensual 
exudation.  Some  women  become  insane,  continue  so  for 
months,  and  recover,  without  any  interruption  of  the  regu- 
larity of  their  monthly  periods.  In  some  the  mental  disorder 
precedes,  while  in  others  it  follows  the  suppression  of  the 
menses.  When  these  have  been  suppressed,  either  before 
or  after  the  invasion  of  insanity,  they  may  return  without 
having  any  curative  effect  upon  the  mental  disease.  Some 
patients  recover  soon  after  the  reappearance  of  them,  others 
before  their  reappearance.  When  the  menses  continue 
regularly  through  the  progress  of  insanity,  in  some  cases 
there  is  an  exacerbation  of  the  physical  and  psychical  excite- 
ment at  the  periods,  but  in  others,  and  I  believe  it  may  be 
said  the  majority,  no  such  exaltation  occurs."  * 

The  above  statement,  which  was  made  only  as  part 
of  an  argument  against  the  then  too  frequent  resort  to 
bleeding  at  asylums,  might  be  fully  allowed,  and  };et 
in  no  way  materially  affect  the  truth  of  the  theory, 
that  upon  the  state  of  the  uterine  system  often  depends 

•  American  Journal  of  Insanity,  x.  398. 


Io6  REFLEX   INSANITY 

the  cerebral  or  mental  integrity  of  women.  The  oc- 
currence or  non-occurrence  of  the  menses,  their  ex- 
istence, deficiency,  or  excess,  are  but  a  single  one  of 
the  many  important  questions  involving  a  reflex  influ- 
ence by  the  uterus  or  ovaries.  But  even  here  it  will 
be  seen  that  there  is  room  in  every  case  for  much 
careful  investigation,  regarding  the  frequency  of  the 
discharge  and  its  coincidence  witli  the  usual  standard, 
as  to  time  of  appearance,  its  duration  and  the  length 
of  the  interval ;  its  abundance  or  deficiency ;  its  con- 
sistence as  to  fluidity,  and  the  presence  or  not  of  clots, 
and  its  odor ;  its  bland  or  irritating  character ;  its 
accompaniment  or  not  by  pain  as  a  precedent,  accom- 
paniment, or  consequent ;  its  alternation,  connection, 
or  supplantation  with  or  by  a  leucorrhoeal  discharge  ; 
all  these  are  points  without  due  attention  to  which  all 
expressions  of  doubt  or  discredit  are  plainly  unfound- 
ed. If  it  be,  as  I  have  suggested,  that  the  depurative 
character  of  the  catamenia  as  eliminating,  alternately 
or  in  conjunction  with  the  lungs,  any  excess  of  carbon 
from  the  system,  is  here  efficiently  in  action,  we  can- 
not by  a  stroke  of  the  pen  destroy  its  influence  upon 
the  causation  of  insanity. 

Allowing  tlie  coincidence  of  mental  and  uterine 
disturbance,  and  that  the  two  are  in  some  way  con- 
nected, it  may  be  asserted  that  the  latter  is  the  conse- 
quence of  the  former,  rather  than  its  cause.     Thus 


IN    WOMEN.  107 

Di.  Kellogg  points  out  that  the  influence  of  strong 
mental  emotion  upon  the  menstrual  secretion  is  very 
marked.  There  are  few  women  of  intelligence  who 
have  not  noticed  the  fact,  and  this  influence  is  partic- 
ularly marked  in  any  of  the  usual  disorders  of  men- 
struation. Menorrhagia  is  almost  invariably  aggra- 
vated by  powerful  mental  emotions.  Some  forms  of 
dysmenorrhoea  are  not  only  caused,  but  rendered  more 
painful,  by  mental  or  moral  disturbance.*  "  Acute 
suppression  of  the  menses  may  arise,"  says  Churchill, 
"  from  a  bodily  or  mental  shock  received  either  just 
previous  to,  or  during  menstruation  ;  "  and  he  gives, 
in  a  note,  the  following  interesting  illustration  of 
this :  — 

"  Almost  all  the  women  who  are  sent  up  to  the  Richmond 
Penitentiary,  after  being  tried  at  the  Recorder's  Court,  labor 
under  suppression  of  the  menses,  in  consequence  of  the 
mental  agitation  and  distress  they  have  undergone  "  f 

The  frequent  occurrence  of  this  result,  I  am  ready 
to  freely  allow ;  but  it  is  no  proof  that  the  converse 
may  not  more  frequently  obtain.  The  twofold  possi- 
bility of  action  and  reaction  is  only  additional  evi- 
dence that  the  sympathy,  which  is  so  constantly  to  be 
observed  between  the  womb  and  the  stomach  or  the 
breasts,  also  exists,  and  to  a  marked  degree,  between 
the  womb  and  the  brain.  This  interchange  of  reflex 
effect,  when  admitted,  tends  to  throw  light  upon  the 

*  Am.  Journal  of  Insanity,  Apr.  1856,  vol.  xii.  p.  315. 
t  Diseases  of  Women,  p.  153. 


loS  REFLEX    INSANITY 

paradox  that  had  puzzled  Dr.  Earle,  who  apparentl)i 
could  not  understand  how  functional  derangement  oi 
functional  crisis  could  in  one  instance  exist  as  effect 
and  in  another  as  cause.  The  coincidence  at  the 
same  time  of  moral  influences,  differing  or  identical, 
would  tend  still  further  to  complicate  the  question, 
which  is,  however,  usually  easily  enough  solved  by 
recollecting  that  more  than  one  derangement  or  lesion 
may  at  one  time  be  present  in  a  single  organ. 

It  will  be  noticed,  moreover,  as  Dr.  Brown-Sequard 
has  claimed  for  the  epileptic  aura,  when  originating 
from  an  otherwise  healthy  womb,*  that  the  irritation, 
though  propagated  from  that  organ,  may  result  from 
an  abnormal  change  in  the  quality  of  the  blood  with- 
in its  vessels,  or  of  its  secretions  other  than  periodical. 

Upon  these  points,  as  they  are  all  of  great  practical 
importance,  I  shall  add  a  few  words  from  Dr.  Buck- 
nill.  It  will  be  seen  that  in  more  than  one  connec- 
tion he  clearly  mistakes  an  eflect  for  the  cause,  and 
the  cause  for  its  eflect.     He  says, — 

"  There  can  be  no  doubt  that  the  sexual  instinct  is  not 
unfrequently  thrown  into  a  state  of  extreme  excitement  by 
pathological  changes  taking  place  in  the  nervous  system. 
This  painful  form  of  disease  not  unfrequently  presents  itself 
during  the  semi-pathological  changes  of  old  age.  Those 
who  have  been  distinguished,  during  a  long  life,  for  prudence 
and  propriety  in  their  relations  with  the  other  sex,  when, 
from  old  age,  they  have  one  foot  in  the  grave,  are  sometimes 
seen  to  throw  off  all  restraint,  and  to  rush   into  the  most 

•  Medical  Times  and  Gazette,  March,  1863. 


IN   WOMEN.  109 

reckless  and  disgusting  libertinism.  Whether  or  not  this 
change  of  manners  is  accompanied  by  diseased  processes  in 
the  brain,  we  have  not  yet  been  able  to  ascertain  by  observa- 
tion. This,  however,  seems  highly  probable,  since  we  have 
seen  nymphomania  end  fatally  in  young  women ;  and  in 
these  cases,  in  addition  to  false  corpora  lutea,  we  have  found 
great  cerebral  congestion.*  Excitement  of  the  sexual  func- 
tions may  depend  upon  spinal  irritation  alone,  the  lascivious 
ideas  being  secondary  results,  just  as  ideas  of  food  are  the 
results  and  not  the  causes  of  hunger.  Nymphomania,  as 
an  example  of  monomania,  is,  therefore,  liable  to  the  objec- 
tion that  it  may  be  a  spinal  or  cerebro-spinal  affection,  and 
independent  of  that  part  of  the  brain  which  is  the  organ  of 
the  mental  [functions]."  f 

The  same  author,  in  another  connection,  again  re- 
fers to  the  matter  just  now  under  consideration,  which 
is  but  one  of  the  many  and  as  yet  but  imperfectly  dis- 
cussed peculiarities  I  might  mention  of  insane  women. 
He  says,  — 

"Every  medical  man  has  observed  the  extraordinary 
amo,unt  of  obscenity  in  thought  and  language  which  breaks 
forth  from  the  most  modest  and  well-nurtured  woman  under 
the  influence  of  puerperal  mania;  and  although  it  may  be 
courteous  and  politic  to  join  in  the  wonder  of  those  around, 
that  such  impurities  could  ever  enter  such  a  mind,  and  while 
he  repudiates  Pope's  slander,  that  '  every  woman  is  at  heart 
a  rake,'  he  will  nevertheless  acknowledge  that  religious  and 
moral  principles  alone  give  strength  to  the  female  mind; 
and  that,  when  these  are  weakened  or  removed  by  disease, 
the  subterranean  fires  become  active,  and  the  crater  gives 
forth  smoke  and  flame."  + 

*  Dr.  Bucknill  forgets  that  the  corpora  lutea  of  menstruation,  the  cicatrices 
of  ovulation  without  impregnation,  are  a  normal  occurrence,  and  that  nympho- 
mania, however  extreme,  may  result  from  the  pruritus  reflexly  produced  by  ute- 
rine disease,  as  for  instance  carcinonia. 

t  Loo.  cit.,  p.  321.  t  Ibid.,  p.  273. 


no  REFLEX   INSANITY 

Esquirol  tells  us  that  women  in  a  state  of  demono- 
mania  experience  a  thousand  peculiar  sensations. 

"  They  believe  they  are  transported  to  the  midnight  assem- 
blies of  wizards,  where  they  are  witnesses  of  the  strangest 
extravagances.  They  have  intimate  communications  with 
the  devil  or  his  subordinates,  after  which,  a  collapse  bring- 
ing an  end  to  the  attack,  they  find  themselves  again  in  the 
same  place  from  whence  they  believed  they  had  been  taken. 
Who  does  not  see  in  this  the  last  stage  of  what,  perhaps, 
commences  with  hysteria.''  Amidst  the  obscenities  of  these 
meetings,  which  we  shall  be  cautious  about  describing,  who 
does  not  recognize  the  turpitude  of  an  imagination  polluted 
by  the  vilest,  most  obscene,  and  disgusting  debauchery? 
Who  does  not  recognize  a  description  of  the  most  extrava- 
gant, shameful,  and  ribald  dreams.?  The  frequent  ecstasies 
which  take  place  in  nervous  affections  partake  of  a  sublime 
and  contemplative  character,  if,  during  its  waking  hours,  the 
soul  is  elevated  to  the  contemplation  of  noble  and  divine 
objects.  They  are  erotic,  if  the  mind  and  heart  lull  them- 
selves in  reveries  of  love.  They  are  obscene,  if  when  awake 
one  indulges  in  lascivious  thoughts,  and  if  the  uterus,  irri- 
tated and  excited,  gives  place  to  illusions  which  are  regarded 
as  diabolical  practices."  * 

Some  psychologists  have  attempted  to  develop  the 
hints  given  above,  by  separating  from  hysteria  what 
they  have  termed  hystero-mania,  this  being  described 
as  "  a  true  mania  developed  upon  a  state  of  hysteria."  f 
In  practice,  however,  it  will  be  found  very  difficult  to 
draw  the  border  line. 

The  fact  just  before  alluded  to  has  not  escaped  the 
notice  of  observers  outside  of  our  own  profession. 

*  Mental  Maladies,  p.  245. 

t  American  Journal  of  Insanity,  October,  i860,  p.  laa 


IN    WOMEN.  Ill 

"It  is  not  all  persons,"  laments  Archbishop  Sharp,  "that 
do  complain  of  these  wicked  and  blasphemous  thoughts  and 
other  extravagant  fancies,  nor  all  good  persons  that  are  thus 
haunted,  but  chiefly  those  that  are  of  a  melancholy  consti- 
tution, or  those  of  the  devout  sex;  women  are  more  thus 
affected  than  the  other  sex.  It  concerns,  therefore,  all  these 
persons  to  look  after  their  bodies,  for  upon  the  cure  and 
health  of  them  the  cure  and  health  of  the  mind  doth,  in  a 
manner,  all  in  all  depend."  * 

Biierre  de  Boismont  very  sensibly  remarks,  — 

"  It  would  be  very  surprising,  if  with  sensations  different 
to  those  which  are  experienced  by  persons  in  health,  the  in- 
valid should  continue  to  reason  the  same  as  such  persons 
do ;  it  is  true,  indeed,  that  the  reason  would  be  perverted 
and  strange."  f 

He  elsewhere,  in  alluding  to  the  fact  that  erotic 
hallucinations  are  far  more  common  in  women  than 
in  men,  endeavors  to  explain  this  difference  by  the 
greater  facility  man  possesses  for  gratifying  his  de- 
sires.J  He  should  have  added  to  this,  that  it  is  more 
especially  owing  to  the  greater  and  more  constant 
predominance  in  women  of  the  sexual  system. 

There  is  an  old  proverb  that  women  advanced  in 
life  become  either  angels  or  devils.  The  change  re- 
ferred to  is  owing  to  the  eflect  upon  them  of  the  con- 
ditions occurring  at  the  grand  climacteric,  as  effective 
for  good  or  evil,  alike  as  regards  mental,  moral,  or 
physical  health,  as  is  the  establishment  of  puberty. 

Attempts  at  explanation  of  these  phenomena  have 

*  Casuistical  Sermons,  vol.  iii.,  London,  1716. 

t  Work  on  Hallucinations,  p.  367.  t  Ibid,  p.  313. 


112  REFLEX   INSANITY 

been  made  upon  other  grounds,  but  upon  examination 
it  is  found  that  the  difference  is  one  of  words  rather 
than  of  ideas.  Thus  Bucknill  would  lay  it  down  as 
a  general  rule  that  in  pure  dementia,  the  sexual  in- 
stinct is  greatly  weakened  or  destroyed.     He  says,  — 

"  This  will  be  found  to  be  the  case  even  in  instances  where 
indecent  conduct  is  observable,  for  such  conduct  would  seem 
to  arise,  not  from  activity  of  the  instinct,  but  from  the  loss 
of  modesty,  and  from  inability  to  appreciate  the  rules  of 
decorum.  In  those  cases  of  senile  insanity  which  are  at- 
tended by  lascivious  conduct,  the  form  of  mental  disease 
more  nearly  approaches  that  of  mania  than  that  of  demen- 
tia. There  is  a  mixture  of  the  two  states,  but  the  maniacal 
element  preponderates."  * 

It  would  seem  that  there  was  here  present  a  bias  to 
erotic  ideas,  without  their  becoming  efficient  in  act 
through  exertion  of  the  will,  just  as  we  frequently  see 
in  general  practice,  where  from  ovarian,  uterine,  va- 
ginal, or  vulval  irritation,  the  most  lascivious  dreams 
and  day-dreams  may  occur,  being  confessed  to  upon 
inquiry  ;  and  yet  the  patient,  though  restrained  by  no 
apparent  check,  evinces  no  symptoms  of  nympho- 
mania, just  as  a  patient  may  be  homicidal  without 
giving  sign  of  what  is  passing  in  her  mind,  or  may 
breathe  threatenings  and  slaughter,  though  in  act  per- 
fectly harmless. 

There  has  still  another  explanation  been  offered ; 
only  occasionally,  however,  possible  of  correct  ap- 
plication.    It  is  thus  stated  by  Esquirol,  who  says 

•  Loc.  cit.,  p.  291. 


IN   WOMEN.  113 

that  "women  of  hysterical  tendencies  have  sometimes 
seen  the  devil  under  the  form  of  a  handsome  and 
well-made  young  man.  Doubtless  libertines,  abus- 
ing the  weakness  of  such  invalids,  may  thus  have 
borrowed  from  the  devil  his  form  and  power.* 

But  it  is  not  women  alone  who  are  here  in  dan- 
ger. The  erotic  fancies  of  the  insane  may  well  be 
looked  for  in  some  of  the  trials  for  bastardy,  rape, 
and  adultery  that  are  brought  before  courts  of  law. 
These  are  no  groundless  fears.  There  are  many 
erotic  patients  who  are  convinced  that  they  have  had 
intimate  relations  with  men  to  whom  they  have 
scarcely  ever  addressed  a  word,  but  by  whom  their 
imagination  has  been  fired.  A  case  to  the  point  is 
familiar  to  most  psychologists.  It  is  that  of  a  lady 
who  attended  the  botanical  course  of  a  celebrated 
French  professor.  After  a  few  lectures  she  persuaded 
herself  that  she  was  pregnant  by  this  gentleman,  ad- 
vanced though  he  was  in  life,  and  to  whom  she  had 
never  spoken.  Nothing  dissuaded  her  from  the  belief. 
The  menses  were  suppressed.  She  became  emaciated 
and  lost  her  appetite.  She  spent  the  eighth  month 
in  preparing  child-bed  linen.  The  ninth  and  tenth 
months  were  passed  without  confinement.  She 
thought  that  the  reason  of  this  was  that  there  were 
no  labor  pains  present,  so  she  stood  for  a  long  time 
upon  her  naked  feet  in  order  to  provoke  them.     She 

*  Esquirol,  loc.  cit.,  p.  246. 


114  REFLEX    INSANITY 

thought  that  she  heard  the  professor  exhorting  her  to 
patience,  and  encouraging  her  to  support  the  throes 
favorable  to  parturition.  In  other  respects  she  was 
perfectly  rational.* 

Brierre  de  Boismont  says,  — 

"While  supposed  intercourse  with  demons  is  less  common 
than  formerly,  the  hallucinations  generally  assume  the  form 
of  an  angel,  or  of  men  gifted  with  all  the  charms  which  the 
imagination  can  bestow  upon  them.  They  frequently  refer 
to  the  head  of  the  asylum."  f 

We  have  thus  far  been  speaking,  it  is  true,  more 
particularly  of  a  single  class  of  cases  of  mental  de- 
rangement, those  attended  with  peculiar  delusions, 
distressing  to  the  last  degree  to  all  the  friends  of  the 
patient.  The  remarks  are  equally  applicable  to  many 
other  forms  of  insanity,  but  here  their  special  causa- 
tion is  often  and  clearly  enough  to  be  distinguished. 
Esquirol  says,  — 

"Irritations,  pains,  and  lesions  of  the  organs  of  genera- 
tion are,  in  some  women  more  particularly,  the  frequent 
cause  of  illusions.     They  have  sometimes,  indeed,  caused 

*  Esquirol,  loc.  cit.,  p.  246. 

t  Hallucinations,  p.  122.  The  last  sentence  of  this  quotation  is  not  uninter- 
esting in  connection  with  some  comments  made  by  my  colleague,  Dr.  Van  Deu- 
sen,  upon  the  communication  made  by  myself  to  the  American  Medical  Associa- 
tion at  the  previous  meeting.  He  says,  in  a  letter  dated  June  28th,  1864,  "  I  was 
not  before  aware  of  the  risks  and  difficulties  experienced  in  making  the  examina- 
tions referred  to.  I  was  not  aware  that  any  superintendent  had  been  charged 
with  any  of  the  improprieties  intimated ;  that  there  had  been  any  legal  examina- 
tion, or  anything  of  the  kind,  to  suggest  as  a  parallel  the  Beale  case,  or  any  oc- 
currence in  this  country  or  elsewhere  to  call  for  the  appointment  of  an  advisory 
medical  board,  upon  that  ground. "  The  quotations  from  the  learned  authorities 
whom  I  have  cited,  prove  the  possibility  of  the  charge,  and  of  its  actual  occur- 
rence, and  at  least  one  case  in  this  country  has  come  to  my  own  knowledge. 


IN    WOMEN.  115 

the  insane  to  mutilate  themselves.  Erotic  female  monoma- 
niacs experience  all  the  phenomena  of  a  union  of  the  sexes. 
They  think  themselves  in  the  arms  of  a  lover  or  ravisher. 
Cancers  and  ulcers  of  the  uterus  are  not  uncommon  among 
them.  The  hysterical  insane  are  disposed  to  attribute  to 
enemies,  to  the  jealous,  and  to  the  devil,  the  constriction 
of  the  throat  which  suffocates  them.  The  flying  pains  which 
they  experience  in  the  limbs  and  viscera,  give  rise  to  the 
most  painful  illusions."* 

Contrary  to  my  general  intention,  I  will  present, 
from  the  same  unexceptionable  authority,  a  few  cases 
of  this  character,  plainly  illustrating,  as  they  do,  the 
physical  cause  of  the  mental  disturbance. 

A.  D.  first  menstruated  at  fourteen.  The  discharge 
was  always  scanty  and  irregular,  and  permanently 
ceased  at  thirty.  She  was  disappointed  in  love  at 
this  time,  and  became  melancholic.  Subsequently 
there  occurred  the  sensation  of  painful  constriction 
of  the  throat,  and  she  was  constantly  rolling  up  the 
skin  of  the  neck  with  her  fingers,  and  crowding  it 
beneath  the  sternum.  There  was  considerable  tension 
of  the  abdomen,  and  this  she  attributed  to  the  devil 
having  extended  a  cord  from  the  sternum  to  the 
pubes,  and  another  around  her  neck,  upon  which  he 
drew,  endeavoring  to  strangle  her. 

In  the  notes  of  the  autopsy  it  is  merely  mentioned 
that  the  abdominal  viscera  were  found  agglutinated 
by  an  old  peritonitis  ;  no  examination  of  the  pelvic 
viscera  seeming  to  have  been  made.f 

*  Loc.  cit.,  p.  us.  t  Esquirol,  loc.  cit.,  p.  239. 


Il6  REFLEX    INSANITY 

M.,  aged  forty-nine,  was  first  unwell  at  fifteen. 
The  menses  ceased  at  forty.  From  this  period  she 
commenced  to  have  headache,  and  gradually  became 
insane.  The  abdomen  was  hard  and  voluminous, 
and  the  patient  had  constantly  her  hand  upon  it. 
She  stated  that  she  had  in  her  uterus  an  evil  spirit  in 
the  form  of  a  serpent,  which  left  her  neither  by  day 
nor  by  night,  and  that  her  organs  of  generation  were 
not  like  those  of  other  women,  although  apparently 
normal.* 

L.  was  a  laundress,  and  had  always  been  very 
devout.  The  menses  commenced  at  fifteen.  She 
married  at  seventeen,  and  became  the  mother  of  fif- 
teen children.  At  forty-six  the  menses  became  very 
irregular,  but  did  not  cease  until  fifty-two,  her  insan- 
ity commencing  during  this  interval.  She  sufiered 
constantly  from  uterine  pains,  and  alleged  that  the 
devil  had  been  her  husband  for  a  million  years,  and 
that  he  was  the  father  of  her  children  ;  that  her  body 
was  a  sack  made  of  the  devil's  skin,  and  filled  with 
serpents,  toads,  and  other  unclean  creatures. f 

A  woman,  who  had  been  subject  to  dysmenorrhoea, 
became  the  mother  of  an  illegitimate  child.  She  af- 
terwards experienced  gastro-intestinal  disturbances, 
and,  as  so  often  occurs,  became  a  bigot.  At  the  final 
cessation  of  the  catamenia  she  became  maniacal,  and 
entered  an  asylum.     She  now  believed  that  Pontius 

*  Ibid.,  p.  34a  t  Ibid.,  p.  24a. 


IN   WOMEN.  117 

Pilate  had  been  the  father  of  her  child,  and  that  he 
had  taken  up  permanent  residence  in  her  bowels, 
where  also  the  popes  held  frequent  council,  being 
visited  at  times  by  the  prophets  and  evangelists,  and 
all  the  illustrious  personages  of  the  Testaments. 

At  the  autopsy,  the  pelvic  viscera  were  found  close- 
ly united  by  peritonitic  adhesions,  but  were  not  prop- 
erly examined. 

Another  patient,  in  whom  the  same  lesion  was  dis- 
covered after  death,  believed  that  she  had  several 
devils  in  her  belly,  who  were  constantly  tempting  her 
to  destroy  herself. 

A  female  monomaniac,  previously  affected  with 
hysteria,  was  convinced  that  serpents  and  other  ani- 
mals, and  even  the  devil,  introduced  themselves  into 
her  body  through  the  genital  organs. 

Another  patient,  in  confinement  at  an  asylum, 
imagined  that  she  had  in  her  bowels  a  regiment  of 
soldiers,  and  that  she  could  feel  them  fighting  and 
struggling  with  each  other.  When  the  pains  were 
exacerbated  she  became  excited,  crying  out  that  the 
soldiers  were  giving  blows  to  each  other  with  their 
weapons,  and  at  the  same  time  were  wounding  her 
entrails.* 

A  woman  insisted  that  she  was  pregnant  by  the 
devil.  She  died,  and  her  womb  was  found  distended 
by  a  mass  of  hydatids.^ 

*  Esquirol,  loc.  cit.,  p.  114.  t  Ibid,  p.  2H. 


Il8  REFLEX   INSANITY 

H.  did  not  menstruate  until  twenty-four  years  of 
age,  and  since  then  had  been  subject  to  headache  and 
colicky  pains.  At  her  third  and  last  confinement, 
she  had  a  difficult  labor,  which  was  followed  by  at- 
tacks of  syncope.  From  this  period  she  imagined 
that  the  devil  had  stolen  her  body,  leaving  only  a 
phantom.* 

"  In  many  cases  of  monomania,"  says  Ray,  "  the 
hallucination  is  excited  and  maintained  by  impres- 
sions propagated  by  diseased  parts,  the  presence  of 
which  has  been  revealed  by  dissection  after  death."  f 

Such  instances  as  these  are  not  uncommon.  I  have 
myself  seen  several  of  them,  but  shall  not  narrate 
them  at  the  present  time,  as  I  wish  here  to  draw  my 
data  from  superintendents  themselves,  whose  author- 
ity and  whose  admissions  cannot  be  gainsaid.  A  case 
almost  identical  with  that  last  given,  and  clearly  de- 
pendent upon  uterine  disease,  was  sent  to  the  Somer- 
ville  Asylum,  by  my  direction,  during  the  last  year. 

Instances  of  supposed  pregnancy  by  the  devil,  or 
criminal  intercourse  with  his  majesty,  are  probably 
more  common  than  was  thought  by  Brierre  de  Bois- 
mont.  A  case  has  been  referred  to  by  many  writers, 
where  exorcism  was  successfully  practised  by  St. 
Bernard.  A  precisely  similar  instance  came  into  my 
own  hands  several  years  since,  in  which  an  equally 
beneficial  result  was  produced  with  the  aid  of  a  priest. 

•  Ibid.,  p.  241.  t  Medical  Jurisprudence  of  Insanity,  p.  159. 


IN    WOMEN.  119 

In  certain  instances,  it  would  not  be  surprising  if  such 
delusions  were  entertained  by  superstitious  minds, 
otherwise  perfectly  sound.  I  refer  to  the  not  uncom- 
mon cases  of  the  so-called  pseudo-cyesis  or  spurious 
pregnancy,  to  which  attention  has  so  forcibly  been 
called  by  Simpson.*  In  this  affection,  as  is  well 
known,  there  are  present  many  of  the  signs  of  preg- 
nancy, enlargement  of  the  abdomen  and  breasts, 
arrest  of  the  menstrual  function,  sympathetic  derange- 
ment of  the  stomach,  and  oftentimes  a  spasmodic  and 
irregularly  clonic  contraction  of  the  recti  and  other 
muscles  of  the  abdomen,  closely  resembling  in  their 
effect  the  movements  of  a  foetus  in  utero.  It  is  some- 
times as  difficult  in  these  instances  to  persuade  the 
patient  herself  that  she  is  not  pregnant,  as  it  is  her 
friends ;  and  if  she  is  conscious  of  never  having  had 
intercourse  with  man,  she  readily  imagines  that  it 
has  been  an  immaculate  or  otherwise  supernatural 
conception. 

But  I  must  defer  to  another  occasion  my  comments 
upon  this  and  similar  points  in  utero-mental  patholo- 
gy, though  the  explanations  that  I  would  offer  are,  I 
believe,  in  their  application  original  and  of  very  prac- 
tical importance. 

There  are  one  or  two  matters,  however,  of  such 
medico-legal  bearing  that  I  should  do  wrong  to  omit 

*  Obstetric  Works,  Scotch  Ed.,  vol.  i.  p.  300;  Clinical  Lectures  on  Disease* 
of  Women,  p.  276. 


I20  REFLEX    INSANITY 

them.  Believing  as  I  do  that  obstetric  jurisprudence 
has  been  one  of  the  most  neglected,  as  it  is  one  of 
the  most  important,  of  the  branches  of  State  medi- 
cine, I  desire,  by  the  investigation  of  these  questions 
relating  to  insanity  in  women,  to  contribute  somewhat 
to  its  advance,  as  I  have  previously  endeavored  to  do 
in  my  treatise  upon  criminal  abortion.* 

The  first  point  to  which  I  shall  allude  may  seem  a 
trivial  one.  It  is  that  of  a  morbid  and  extreme  fond- 
ness for  pets,  among  women  living  solitary  or  se- 
cluded lives,  and  is  most  commonly  brought  out  in 
courts  during  the  decision  of  civil  cases.  In  one  suit, 
for  instance,  that  is  on  record,  it  was  charged  that  the 
testatrix  was  insane,  because  she  kept  fourteen  dogs 
of  both  sexes,  with  their  kennels,  in  her  drawing- 
room  ;  two  of  them  slept  in  her  chamber,  and  one  of 
them,  which  was  blind,  in  the  same  bed  with  her ;  f 
another  lady  kept  her  sitting-room  filled  with  mon- 
keys, to  the  great  annoyance  of  her  visitors ;  others 
have  not  been  happy  unless  surrounded  by  parrots, 
or  their  room  converted  into  aviaries  for  all  kinds  of 
birds.  In  one  celebrated  case,  that  of  Mrs.  Cum- 
mings,  there  was  exhibited  a  propensity  for  cats, 
which  were  provided  with  their  meals  at  table  at 
regular  hours,  and  were  furnished  with  napkins.J 

*  Criminal  Abortion  in  America :  Philadelphia,  Lippincott  &  Co.,  i86a 
Criminal  Abortion ;  its  Nature,  its  Evidence,  and  its  Laws :  Boston,  Little, 
Brown  &  Co.,  1869. 

t  Yglesias  v.  Dyke,  Prerog.  Court,  185c 

%  Taylor,  Medical  Jurisprudence,  p.  658.  See  also  Dryden  v.  Fryer,  Q.  B., 
Dec.  1850;  Journal  of  Psychological  Medicine,  1851,  p.  285. 


IN    WOMEN.  121 

"  This  propensity  for  animals  proves  nothing  in 
relation  to  the  existence  of  insanity,"  says  Taylor, 
"unless  there  is  good  evidence  of  mental  aberration." 
On  the  other  hand,  it  has  often  been  illustrative  of 
decided  monomania,  and  I  believe  is  generally  de- 
pendent upon  ovarian  or  uterine  irritation. 

Within  a  few  years  a  class  of  cases  has  made  its 
appearance,  exceedingly  embarrassing  to  the  medical 
jurist.  These  cases  are  not  uncommon.  Their  de- 
scription I  shall  now  submit,  from  Dr.  Ray. 

"The  woman,  after  preparing  for  a  union  to  which  her 
head  and  heart  had  apparently  fully  consented,  and  going 
through  the  marriage  ceremony  with  the  utmost  propriety, 
manifesting  all  the  while  nothing  unusual  in  her  deport- 
ment, immediately  after  imbibes  an  insuperable  aversion 
towards  her  husband,  shuns  his  company,  and  perhaps  re- 
fuses to  live  with  him.  In  some  of  the  cases,  other  singu- 
larities of  conduct  soon  appear,  one  after  another,  till  at 
last  the  woman  becomes  a  subject  of  unequivocal  insanity. 
In  others,  however,  this  strong  repugnance  towards  the 
husband  continues  to  be  the  principal,  if  not  the  only, 
symptom  of  mental  disorder;  but  so  closely  do  they  resem- 
ble the  former  in  other  respects,  that  we  can  have  no  hes- 
itation in  regarding  them  as  merely  varieties  of  the  same 
affection.  The  pathological  character  of  these  cases  seems 
to  be  sufficiently  obvious.  From  some  cause  or  other,  the 
patient  has  been  affected  with  a  cerebral  irritation,  not  suffi- 
cient to  disturb  the  mental  manifestations,  and  which,  under 
favorable  circumstances,  might  have  entirely  disappeared. 
In  this  condition,  marriage,  with  the  crowd  of  new  thoughts 
and  feelings  by  which  it  is  preceded,  operates  as  a  power- 
fully exciting  cause,  and  under  its  influence  the  pathological 
affection  is  completely  developed.  It  is  not  strange,  cer- 
tainly, that  marriage  should  occasionally  find  a  female  brain 


122  REFLEX    INSANITY 

ID  this  morbid  condition ;  nor  that,  in  case  of  such  a  con- 
junction, the  result  here  mentioned  should  follow.  The 
legal  relations  of  these  cases  are  not  so  satisfactorily  settled. 
In  some  of  them,  a  close  scrutiny  of  the  conduct  and  con- 
dition previous  to  marriage  may  detect  indubitable  signs  of 
insanity;  while  in  others  no  such  signs  can  be  discovered, 
though  subsequently  the  mental  disorder  may  have  become 
no  less  obvious.  Now,  are  we  prepared  to  make  a  distinction 
between  them.?  To  grant  divorce  in  one  class  and  refuse  it 
in  the  other.?  This,  no  doubt,  would  be  highly  convenient, 
but  we  are  not  sure  that  it  would  be  strictly  just.  While  we 
see  not  how  legal  relief  can  be  withheld  in  the  former  class, 
yet  in  regard  to  the  latter,  we  recoil  from  the  idea  of  de- 
priving a  woman  of  her  protection  and  support  at  the  very 
moment  when  the  severest  of  earthly  calamities  has  over- 
taken her,  merely  on  the  strength  of  what  we  may  call  a 
pathological  abstraction."  * 

To  the  explanation  above  given  by  Dr.  Ray,  I 
will  add  two  others,  which  seem  to  have  escaped  his 
notice.  In  some  of  these  cases  the  woman  gets  her 
first  intimation,  at  or  soon  after  the  time  of  marriage, 
that  her  husband  has  previously  had  to  do  with  others 
of  her  sex,  and,  as  in  more  than  one  instance  that  has 
come  to  my  knowledge,  she  shows  her  disappoint- 
ment and  her  disgust  accordingly.  In  other  cases, 
as  is  well  known,  the  conjugal  approach  is  attended 
with  excessive  pain.  This  effect,  normal  with  the 
first  coitus,  at  times  becomes  persistent  and  a  veritable 
disease ;  exhibiting  itself  either  in  the  hyperaesthesia 
of  the  vulva,  which  has  been  termed  vaginismus  by  Dr. 

*  Medical  Junsprudence  of  Insanity,  p.  340- 


IN    WOMEN.  123 

Marion  Sims,  or  In  an  extreme  sensibil;ty  to  touch  on 
the  part  of  the  uterus  itself.  Of  both  these  affections 
I  have  seen  many  cases ;  in  one  of  the  former,  the 
husband  had  applied  for  a  divorce  on  the  ground  that 
his  wife  is  an  hermaphrodite,  whereas  she  is  in  reality 
perfectly  formed.  In  one  of  the  latter,  the  patient 
having  been  sent  to  me  by  Dr.  Walker,  of  the  City 
Lunatic  Hospital  at  South  Boston,  on  the  ground  that 
insanity  was  threatened,  the  husbandj  he  said,  had 
been  driven  to  adultery  by  the  practical  uselessness, 
for  marital  purposes,  of  his  wife. 

I  have  spoken  of  obscenity  and  lascivious  conduct 
in  women,  as  the  result  of  disease.  There  is  no  doubt 
that  the  same  explanation  is  applicable  to  a  large 
proportion  of  the  cases  of  so-called  self-abuse,  which 
are  not  uncommon,  and  are  frequently  carried  to  an 
insane  extreme  ;  though  insanity,  as  its  consequence, 
is  less  freqrently  occasioned  than  in  men,  from  the 
absence  of  a  corresponding  exhaustive  discharge.  So 
far  from  being  considered  and  treated  as  a  vice,  or 
from  being  considered  and  treated  only  by  moral 
means,  these  cases  should  very  frequently  be  con- 
ducted as  any  others  of  physical  disease.  The  imta- 
tion  of  ascarides,  haemorrhoids,  or  mere  constipation, 
of  morbid  states  of  the  catamenia,  of  the  urine,  or  of 
the  vaginal  secretions,  or  lesions  of  the  organs  them- 
selves, may  each  and  all  of  them  rest  at  the  foundation 


124  REFLEX    INSANITY 

of  the  habit,  as  efficient  causes,  without  whose  removal 
no  cure  can  be  hoped  for  or  obtained.* 

There  are  other  cases,  to  a  still  greater  degree  in- 
volving the  mental  integrity  and  the  moral  responsi- 
bility of  women.  Cases  of  intemperance,  habitual  or 
periodical,  of  mendacity,  of  theft,  of  jealousy,  of  homi- 
cide. Had  I  not  already  trespassed  so  largely  upon 
the  patience  of  the  Association,  I  would  present  at 
this  time  the  valuable  material  I  have  in  my  possession 
relating  to  what  I  consider  should  be  the  true  legal 
responsibilities  of  woman,  their  extent,  and  whether 
they  should  be  confined,  either  as  regards  their  charac- 
ter, or  the  time  of  their  occurrence,  to  any  particular 
periods  or  epochs  of  her  life.  This  subject  has  not 
escaped  the  observation  of  Michelet,t  and  in  reference 
to  its  relations  with  pregnancy  has  attracted  the  at- 
tention of  Sedgwick  J  and  others.  §  I  believe  not 
only  that  the  execution  of  pregnant  women  should 
be  stayed  for  the  sake  of  the  life  of  the  child,  examina- 
tion by  a  jury  of  matrons,  instead  of  by  skilled  medical 
men,  being  a  farce,  whose  occurrence  at  the  present 
day  is  alike  a  disgrace  to  the  law  and  to  civilization  ; 
but  that  no  pregnant  or  parturient  woman,  for  a  crime 
committed  during  her  gestation,  or  shortly  after  her 
confinement,  should  ever  be  executed  at  all. 

*  Seethe  Journal  of  the  Gynxcological  Society  of  Boston,  August,  187a  p.  100. 

t  L' Amour,  p.  334. 

t  Medical  Critic  and  Psychological  Journal,  October,  1863,  p.  694. 

J  American  Journal  of  Insanity,  January,  1856.  p.  295- 


IN   WOMEN.  125 

A  few  words  upon  this  point,  based  upon  sound 
analogy,  I  shall  extract  from  the  work  of  a  well- 
known  and  well-educated  veterinary  surgeon,  and  shall 
incidentally  refer  to  the  subject  again  in  the  course  of 
this  report. 

Mayhew  says, — 

"  Some  bitches  cannot  be  induced  to  suckle  the  pups  they 
have  given  birth  to,  and  others,  though  less  frequently,  wrill 
eat  their  progeny.  The  disposition  to  desert  or  destroy  their 
young  seems  to  prevail  among  the  parentage  of  this  world. 
In  the  female  of  the  dog  the  maternal  instinct  is  most  power- 
ful;  but  under  certain  conditions  of  the  animal's  body,  the 
natural  impulse  seems  to  be  perverted,  and  she  takes  the 
life  she  would  else  have  perished  to  preserve.  It  is  painful, 
knowing  this,  to  reflect  that  on  his  own  species  man  inflicts 
the  highest  punishment  for  an  act  that  possibly  may  be,  in 
the  human  being  as  in  brutes,  the  consequence  of  a  mental 
excitement  accompanying  the  period  of  parturition.  Women 
not  in  distress  and  otherwise  aflflicted,  rarely  indeed  are 
guilty  of  infanticide;  and  I  have  observed  annoyance  of  ill 
health  precede  or  accompany  the  like  act  in  animals.  If  the 
rabbit  be  looked  at,  her  alarm  seems  to  change  her  nature ; 
and  the  bitch  that  devours  her  pups  will,  upon  inquiry,  be 
generally  found  to  have  suffered  some  species  of  persecution. 
That  the  brain  is  affected  there  can  be  no  doubt.  The  un- 
natural propensity  is  itself  a  proof;  but  the  strange  appear- 
ance and  altered  looks  of  the  creature  sufficiently  denote  her 
state.  She  is  not  then  savage,  her  ferocity  has  been  grati- 
fied, and  she  seems  rather  to  be  afflicted  with  a  remembrance 
of  the  acts  she  was  unable  to  resist.  She  is  the  picture  of 
shame;  she  shrinks  away  at  our  approach,  and  her  eye  no 
longer  confidently  seeks  that  of  her  master;  her  aspect  is 
dejected,  but  I  think  more  with  sorrow  than  with  crime.  I 
would  not  plead  for  sin ;  but  what  I  have  beheld  in  dogs  in- 
duces me  to  think  that  the  majority  of  those  who  have  been 
hung  for  infanticide  were  legally  murdered.     There  is  dan- 


126  REFLEX    INSANITY 

ger  in  admitting  such  an  opinion;  but  seeing  all  animals  at 
certain  periods  exhibit  a  certain  propensity,  it  is  "ery  doubt- 
ful whether  the  morbid  feeling,  as  txemplified  in  the  human 
race,  is  really  one  that  calls  for  moital  punishment."  ♦ 

Jorg,  of  Leipsic,  who  erred  in  his  estimate  of  the 
legal  and  real  value  of  the  human  fcetus,  as  I  have 
elsewhere  shown,!  has  expressed  a  very  sensible 
opinion  upon  the  responsibility  of  women  during 
pregnancy  and  parturition,  believing  that  pregnancy 
can  so  disturb  the  intellectual  faculties  that  the  patient 
becomes  unable  to  control  her  propensities. J  Mont- 
gomery, on  the  other  hand,  one  of  the  most  profound 
and  most  classical  writers  of  modern  medicine,  be- 
lieves that  "  this  doctrine  is  as  abhorrent  from  truth 
and  nature,  as  it  is  calculated  to  lead  to  the  most 
serious  consequences,"  §  thus  indorsing  the  views  of 
Capuron  and  Devergie,  who  considered  that  such  an 
opinion  as  I  have  described  "  would,  by  taking  away 
all  moral  responsibility,  be  fraught  with  most  dis- 
astrous results  to  society  ;  "  \\  although,  as  I  shall  now 
show,  the  Irish  physician,  like  many  another  close 
observer  who  does  not  dare  to  follow  his  own  data  to 
their  legitimate  conclusions,  most  emphatically  con- 
tradicts himself. 

•  Dogs:  their  Management,  p.  217. 

t  Criminal  Abortion  in  America,  p.  58. 

t  Die  ZurechnungsfShigkeit  der  Schwangem  und  Gebarenden. 

§  Signs  and  Symptoms  of  Pregnancy,  p.  39. 

I  M^decine  Legale,  L  p.  433. 


IN  WOMEN.  127 


VII.  —  Rationale  of   Pelvic   Causation  of 
Insanity. 

As  throwing  some  light  upon  the  theory  of  ihe 
causation  of  insanity  in  woman  by  reflex  uterine  ac- 
tion, or  what  Forbes  Winslow  has  called  the  dynam- 
ical sympathies  of  the  reproductive  organs,*  it  may 
not  be  amiss  if  I  present  a  few  remarks  concerning 
the  nervous  derangements  of  pregnancy,  from  the 
iauthor  I  have  just  quoted,  my  friend,  the  late  Dr. 
Montgomery  of  Dublin.  I  have  selected  the  period 
of  pregnancy  rather  than  the  puerperal  state,  con- 
cerning the  mental  disturbances  of  which  we  have 
had  so  much  light  from  the  pens  of  Dr.  Gooch,  and 
more  recently  Drs.  Gundry  of  the  Dayton  Asylum, 
and  Simpson  of  Edinburgh :  because  pregnancy,  in 
itself  considered,  is  rather  a  normal  and  physiological, 
than  a  pathological  condition,  its  mental  abnormal 
manifestations  being  of  almost  identical  character  with 
those  attending  the  catamenial  crises  and  climacteric 
epochs,  lesser  or  greater,  not  more  frequently  evinced 
than  at  these  times,  nor  more  decidedly,  if  indeed  they 
are  not  softened  down  and  palliated  by  the  influence 
of  gestation,  as  sometimes  seems  to  be  the  case. 
W^hether  this,  however,  or  the  converse  be  true,  there 
can  be  no  doubt  that  the  manifestations  to  which  I 

•  Journal  of  Psychological  Medicine,  April,  1854,  p.  474. 


128  REFJ.EX    INSANITY 

would   refer  are  clearly  and    undoubtedly  of  sexual 
origin.     Montgomery  says,  — 

"When  speaking  of  the  physical  changes  which  the  uter 
ine  system  undergoes  in  consequence  of  impregnation,  it 
was  remarked  that  the  nerves  distributed  to  the  organ  and 
its  appendages  were  augmented  in  size  and  number,  and 
having  their  sensibility  exalted,*  diffused  throughout  the 
system  generally  an  increase  of  nervous  irritability,  which, 
affecting  both  mind  and  body,  displays  itself  under  a  great 
variety  of  forms  and  circumstances,  rendering  the  female 
much  more  excitable  and  more  easily  affected  by  external 
agencies;  especially  those  which  suddenly  produce  strong 
mental  or  moral  emotions,  whether  of  the  exhilarating  or 
depressing  kind,  as  fear,  joy,  sorrow,  anger.  The  powerful 
influence  of  such  impressions  over  the  functions  and  actions 
of  the  uterus,  in  every  stage  of  female  life  after  puberty,  is 
recognized  in  a  multiplicity  of  circumstances,  whether  as 
deranging  menstruation,  inducing  abortion,  modifying  the 
energy  of  parturient  action,  or  affecting  the  recovery  from 
childbed. t  Hence  the  importance  of  preventing,  as  far  as 
possible,  pregnant  women  from  being  exposed  to  causes 
likely  to  distress,  or  otherwise  strongly  impress  their  minds. 
Sights  of  an  affecting  kind,  books,  pictures,  or  theatrical 
representations,  which  may  deeply  excite  the  imagination, 
or  engage  the  feelings,  are  decidedly  unsafe,  and,  in  illus- 
tration of  the  dangers  which  may  thence  arise,  I  shall  men- 
tion one  or  two  instances. 

"  I  was  once  urgently  called  to  see  a  lady  who  had  gone  to 
the  theatre,  when  two  months  pregnant,  to  witness  some 
grand  spectacle,  in  which  armed  knights  on  horseback  were 
to  cross  a  bridge  and  storm  a  castle ;  while  doing  so,  the 
bridge  gave  way,  and  the  besiegers  were  precipitated  into 
the  torrent  beneath,  and  some  of  them  much   hurt.     The 

*  It  is  not  necessary  to  suppose  the  uterine  nerves  augmented,  either  in  siz'j 
or  in  number,  to  account  for  an  exaltation  of  their  sensibility. 

t  Burrows:  Conuiientaries  on  Insanity,  p.  378;  Merriman:  Synopsis,  etc.,  pp 
33.324- 


IN   WOMEN.  129 

lady  was  dreadfully  terrified,  screamed,  fainted,  and  was 
carried  home  almost  insensible,  when  it  was  discovered  that 
she  was  flooding  profusely;  under  the  influence  of  which, 
and  the  previous  fright,  she  soon  became  alarmingly  ex- 
hausted. However,  by  the  adoption  of  proper  measures, 
she  was  restored  and  tranquillized ;  but  she  miscarried  before 
morning.  Another  case  was  that  of  a  lady,  who,  after  pass- 
ing several  years  of  her  life  in  straitened  circumstances,  and 
actively  employed,  married  when  no  longer  very  young,  and 
was  thereby  placed  in  a  position  of  comparative  affluence, 
which,  unfortunately  for  herself,  enabled  her  to  dispense 
with  any  further  exertion,  and  to  indulge  a  natural  inclina- 
tion to  indolence  and  sedentary  habits.  She  soon  became 
pregnant,  and  spent  her  whole  time  lying  on  a  sofa  at  the 
fireside,  or  with  her  feet  on  the  fender,  reading  novels,  eat- 
ing and  drinking  heartily,  and  having  a  discharge  from  the 
bowels  perhaps  once  or  twice  in  the  week.  Amongst  the 
books  which  she  thus  daily  devoured,  was  one  containing  a 
highly-wrought  description  of  one  of  the  Maisons  de  Sante 
in  France,  and  of  its  inmates;  this  aff'ected  her  strongly, 
and  took  great  hold  on  her  mind,  and  she  expressed  the 
greatest  desire  to  visit  one  of  the  large  lunatic  asylums  in 
this  city,  that  she  might  assure  herself  of  the  reality  of  such 
things  as  she  had  been  reading  of.  In  this  wish  she  was 
indulged,  as  in  everything  else,  whether  right  or  wrong,  to 
which  she  took  a  fancy;  and  the  consequence  was,  that  the 
appearance  of  the  persons  she  had  seen,  and  their  extrava- 
gant expressions  and  gesticulations,  continued  to  haunt  her 
imagination  incessantly  up  to  the  time  of  her  delivery;  on 
the  third  day  after  which  she  showed  sj^mptoms  of  insanity, 
which  became  rapidly  confirmed,  and  continued  for  many 
months.  During  her  illness,  and  after  her  recovery,  she  re- 
peatedly told  me  that  from  the  time  of  reading  the  book  and 
visiting  the  asylum,  she  felt  as  if  she  would  certainly  become 
deranged.* 

"The   irritation  of  the   nervous  system  is   in  some  most 
obviously  perceived  in  the  change   induced  in   the  moral 

*  Signs  aivd  Symptoms  of  Pregnancy,  p.  17. 

9 


130  REFLEX   INSANITY 

temperament,*  rendering  the  individual  depressed  and  de- 
spondent, or,  perhaps,  she  who  was  naturally  placid  and 
sweet-tempered,  becomes  peevish,  irritable,  and  capricious 
to  a  degree  as  distressing  to  herself  as  it  is  disagreeable  to 
others ;  yet  over  this  she  has  little  control,  and,  therefore, 
much  allowance  must  be  made  for  such  waywardness,  which, 
instead  of  exciting  opposition,  resentment,  or  reproach, 
sliould  claim  our  utmost  indulgence  and  commiseration,'  and 
our  best  endeavors  to  comfort,  soothe,  and  cheer.  A  lady 
of  rank  and  very  superior  acquirements  told  me,"  he  con- 
tinues, "  that  for  the  first  two  or  three  months  of  her  preg- 
nancies, she  became  so  irritable  that,  to  use  her  own  words, 
she  was  a  perfect  nuisance  in  her  house,  and  was  so  pain- 
fully conscious  of  it  herself,  that  she  would  sometimes  re- 
main in  bed  all  day,  or  confine  herself  to  her  room,  to  avoid 
displaying  her  irritability  to  the  annoyance  of  others.  This 
lady  has  since  died  of  cancer  uteri,  under  the  most  deplora- 
ble circumstances. 

"  I  have  known  the  effect  produced  to  be  the  reverse  of 
this,  and  a  decided  amelioration  take  place  in  the  temper, 
as  we  sometimes  also  see  happen  in  the  exercise  of  the 
bodily  functions  during  pregnancy,  A  gentleman  once  in- 
formed me  that,  being  afflicted  with  a  stepmother  naturally 
more  disposed  to  practise  the  fortiter  in  re  than  to  adopt  the 
suaviter  in  modo,  he  and  all  the  household  had  learned, 
from  experience,  to  hail  with  joyful  anticipations  the  lady's 
pregnancy  as  a  period  when  clouds  and  storm  were  imme- 
diately exchanged  for  sunshine  and  quietness. 

"  Some  sufter  most  from  this  irritability  depriving  them 
of  sleep,  night  after  night,  especially  if  they  have  not 
guarded  against  feverishness  by  pro|>er  attention  to  the  state 
of  the  bowels,  or  sleep  in  rooms  too  warm  or  insufficientlv 
ventilated;  and  yet  it  is  singular  how  little  they  appear  to 
suffer  from  this  loss  of  rest,  seeming  really  as  much  re- 
cruited by  the  short  snatches  of  sleep  which  they  obtain  as 
they  would,  at  other  times,  when  enjoying  unbroken  repose. 
Others  sleep,  but  suffer  even  more  from  painful  and  distress 

•  Har\ey,  4to.  edition,  p.  593. 


IN   WOMEN. 


131 


ing  dreams;  while  some  are  liable  to  annoyance  of  a  to- 
tally different  kind,  being  constantly  so  drowsy,  that  it  is 
with  difficulty  they  can  keep  awake,  even  in  company. 

"  I  suppose  many  have  noticed  a  curious  fact  connected 
*vith  the  state  of  mind  in  pregnant  women,  when  their  bod- 
ily health  is  at  the  sanie  time  good,  namely,  that  however 
depressed  or  dispirited  with  gloomy  forebodings  they  may 
have  felf  in  the  early  part  of  their  pregnancy,  they,  in 
general,  gradually  resume  their  natural  cheerfulness  as 
gestation  advances,  and,  a  short  time  before  labor  actually 
commences,  often  feel  their  spirits  rise  and  their  bodily 
activity  increase  to  a  degree  that  they  had  not  enjoyed  for 
months  before.  I  have  known  instances  in  which  this  took 
place  so  regularly  and  distinctly,  in  successive  pregnancies, 
that  the  patients  were  able,  from  its  occurrence,  to  anticipate 
and  announce  the  near  approach  of  their  labor.  This  must 
strike  us  as  a  wise  and  beautiful  arrangement  by  which,  on 
the  eve  of  suffering,  the  mind  rises  with  a  spring  to  meet 
the  trial  with  cheerfulness  and  fortitude,  which  experience 
proves  so  materially  to  contribute  to  a  happy  result. 

"  Occasionally,  however,  the  depression  assumes  a  more 
serious  aspect,  and  the  woman  is  constantly  under  the  influ- 
ence of  a  settled  and  gloomy  anticipation  of  evil,  sometimes 
accompanied  with  that  sort  of  apathetic  indifference  which 
makes  her  careless  of  everj-  object  that  ought  naturally  to 
awaken  an  interest  in  her  feelings;  a  state  which  we  some- 
times observe  in  fever  and  other  severe  disorders,  in  which 
it  is  justly  considered  a  most  unfavorable  symptom.  When 
this  occurs  in  pregnancy,  it  will  generally  be  found  accom- 
panied by  very  evident  derangements  in  bodily  health;  a 
dull  heaviness,  or  aching  of  the  head,  a  loaded  tongue  with 
bitter  taste  in  the  mouth,  constant  nausea,  costiveness,  and 
a  foul  state  of  the  alvine  discharges,  with  not  unfrequently 
a  bilious  tinge  in  the  skin,  and  other  symptoms  indicating 
hepatic  derangement,  together  with  a  quick  pulse  and  a  dry, 
hot  skin,  constitute  the  group  of  symptoms  likely  to  be 
present,  and  which  urgently  demand  attention  for  their 
removal  before  the  time  of  labor,  otherwise  serious  con- 


133  REFLEX    INSANITY 

sequences  are  to  be  apprehended.  Sometimes  this  state 
appears  to  depend  on  some  peculiar  condition  of  the  brain, 
the  nature  of  which  we  probably  cannot  appreciate,  and 
which  our  treatment  will  but  too  often  fail  to  correct; 
in  one  strongly-marked  instance  of  this  kind,  which  was 
some  time  ago  under  my  care,  the  lady  became  maniacal  on 
the  fifth  day  after  delivery,  and  continued  deranged  for 
many  months." 

Reasoning  by  analogy  from  such  considerations  as 
those  we  have  just  been  engaged  in,  we  should  be 
led  to  expect  as  probable,  what  experience  confirms 
as  certain,  that  occasionally  the  cerebral  disturbance 
during  pregnancy,  which,  in  most  instances,  only 
shows  itself  in  unevenness  of  spirits,  or  irritability 
of  manner  or  temper,  amounts  in  some  to  absolute 
disorder  in  the  intellectual  faculties,  especially  in 
habits  naturally  very  excitable,  or  where  there  is  an 
hereditary  predisposition.     Dr.  Pilchard  says,  — 

"  If  we  consider  the  frequent  changes  or  disturbances 
occurring  in  the  balance  of  the  circulation  from  the  varying 
and  quickly  succeeding  processes  which  are  carried  on  in 
the  system  during  and  soon  after  the  periods  of  pregnancy 
and  childbirth,  we  shall  be  at  no  loss  to  discover  circum- 
stances under  which  a  susceptible  constitution  is  likely  to 
suffer.  The  conversions,  or  successive  changes  in  the  tem- 
porary local  determinations  of  blood,  which  the  constitution 
under  such  circumstances  sustains  and  requires,  appear 
sufficiently  to  account  for  the  morbid  susceptibility  of  the 
brain."  * 

•'  One  cannot  deny,"  says  Roussel,  "  that  the  minds 
of  pregnant  women  are  singularly  modified  ;  "  f  and 

•  Treatise  on  Insanity,  p.  31a.  t  Systeme  de  la  Feinme,  p.  i6a 


IN    WOMEN.  133 

this  susceptibility  to  mental  disturbance,  on  the  part 
of  the  mother,  has  been  recognized  on  high  authority 
as  giving  rise  to  one  species  of  congenital  predisposi- 
tion to  insanity  in  the  offspring.  In  some,  this  sen- 
sorial agitation  may  be  confined  to  the  more  strongly 
marked  forms  of  hysteria,  or  only  exhibit  itself 
in  those  unaccountable  phantasies  called  longings, 
"  which,"  says  Dr.  Burrows,  "  are  decided  perver- 
sions or  aberrations  of  the  judgment,  though  perhaps 
the  simplest  modifications  of  intellectual  derange- 
ment," *  but  in  others  it  is  truly,  and  even  violently, 
maniacal.  "  I  have,  on  one  occasion,"  says  Mont- 
gomery, "  noticed  a  case  where  mania  occurred  in 
eight  successive  pregnancies,  and  another  in  which 
the  woman  was  three  times  similarly  affected  soon 
after  conception,  and  remained  deranged  until  within 
a  short  time  of  her  labor,  when  she  became  sane,  and 
continued  so  until  the  recurrence  of  pregnancy."  f 
"  Some,"  again  remarks  the  author  last  quoted,  "  are 
insane  in  every  pregnancy  or  lying-in,  others,  only 
occasionally."  J  Marc,  writing  on  the  same  subject, 
says,  "  I  recall  a  patient  in  Esquirol's  Asylum,  in 
whose  case  the  commencement  of  each  pregnancy 
was  characterized  by  an  attack  of  transient  insanity."  § 
Goubelly  relates  a  case  of  an  opposite  kind,  in 
which  the  lady  was  of  sound  mind  only  during  her 

•  Commentaries  on  Insanity,  p.  147.        t  Dublin  Medical  Journal,  v.  p.  52. 
t  Loc  cit.,  pp.  364-378.  §  Diet,  de  Sc.  Med.,  xix.  p.  489. 


134  REFLEX   INSANITY 

pregnancies,  but  was  then  deficient  in  memory ;  of 

which    latter  defect   the   following   is  a   remarkable 

instance :  — 

"  A  fright  produced  by  the  dangerous  situation  of  her  only 
son  when  eighteen  months  old,  brought  on,  in  Mrs.  Durant, 
an  alarming  illness,  attended  with  some  singular  phenome- 
na, the  most  singular  of  which  respected  her  memory.  The 
illness  happened  in  July,  when  she  was  advanced  six  months 
in  a  state  of  pregnancy,  and  was,  when  perfectly  insensible, 
delivered  of  a  child.  On  awaking  from  her  insensibility, 
which  had  continued  for  three  days,  she  imagined  it  was  the 
month  of  January.  Her  mental  powers  generally  were  but 
slightly  impaired,  and  soon  regained  their  former  perfection  ; 
nor  was  her  memory  affected,  except  as  regarded  the  pre- 
ceding six  months.  Of  that  time  she  had  forgotten  all  the 
events  :  some  accidental  circumstance  might  afterwards  oc- 
casionally produce  a  train  of  thought,  which  would  bring  an 
event  of  those  six  months  to  her  recollection ;  but  several 
of  the  most  important  were  never  regained,  nor  could  she,  to 
the  hour  of  her  death,  remember  that  she  had  then  been  preg- 
nant. I  have  met  with  a  few  instances  in  which  the  memory 
was  similarly  effaced,  and  under  apparently  similar  circum- 
stances, but  for  much  shorter  periods  of  time."* 

It  has  been  asserted  that  manifestations  such  as 
those  we  have  now  seen  described,  whether  occurring 
in  pregnancy,  at  or  after  childbed,  or  during  any  other 
time  of  a  woman's  life,  are  merely  attacks  of  hysteria, 
as  distinguished  from  actual  insanity,  more  or  less 
aggravated  as  these  may  be.  The  error  of  such  a 
supposition  has  been  allowed  by  more  than  one  psy- 
chologist. I  have  already  called  attention  to  the 
similar  error  of  endeavoring  to  separate  in  all  cases 

*  Montgomery,  Signs  and  Symptoms  of  Pregnancy,  pp.  32-37- 


IN   WOMEN.  135 

from  hysteria  the  so-called  hystero-mania.  In  some 
cases,  however,  of  hysteria,  the  mania  may  be  coun- 
terfeited.    Dr.  Bucknill  says,  — 

*'  The  diagnosis  between  exaggerated  hysteria  and  in- 
complete primary  mania  must  be  made  by  observing  the 
sex,  age,  consthtution,  and  character  of  the  patient,  which, 
to  the  experienced  physician,  will  generally  reveal  the  nature 
of  hysterical  attacks,  whatever  form  they  may  assume. 
They  do  sometimes  assume  the  form  of  mania,  with  violent 
general  excitement  and  strongly  pronounced  moral  per- 
versions. These  may  be  looked  upon  as  the  proper  symp- 
toms of  the  disease  ;  but  hysterical  patients  have  been  known 
to  feign  delusions  and  hallucinations,  just  as  they  will  feign 
everything  else.  The  hysterical  type  of  the  patient,  the 
paroxysmal  nature  of  the  excitement,  and  the  contradictions 
in  which  she  may  be  detected  when  closely  examined  upon 
the  circumstances  of  her  supposed  delusions,  will  rarely  fail 
to  detect  the  comparatively  harmless  nature  of  the  affection. 
This  will  be  the  more  easy,  if  the  effect  of  remedies  appro- 
priate to  hysteria  can  be  tried.  But  hysteria  does  some- 
times pass  into  real  mania,  and  carry  with  it  some  of  its 
own  peculiarities.  In  all  the  instances  in  which  we  have 
observed  this  transition,  there  has  been  a  strong  hereditary 
tendency  to  insanity.  The  transition  has  been  marked  by 
an  obvious  febrile  crisis,  and  by  that  most  important  symp- 
tom of  early  mania,  loss  of  sleep.  The  medical  man  must, 
therefore,  exercise  due  caution,  in  avoiding  to  pronounce 
any  case  to  be  purely  hysterical  because  it  has  once  been  so. 
If,  in  a  young  woman  of  hysterical  temperament,  the  per- 
verted sentiments  and  desires,  the  strange  conduct  and  ex- 
cited demeanor  pass  into  a  febrile  stage,  accompanied  by  a 
rapid  pulse,  by  loss  of  sleep,  and  by  delusion  or  hallucina- 
tion, hysteria  has  passed  into  mania.  Patients  are  even  met 
with,  in  whom  periods  of  hysterical  and  maniacal  excite- 
ment alternate;  and  it  is  not  difficult  to  distinguish  in 
them    the    period  when   the    superficial  disorder    presents 


136  REFLEX    INSANITY 

itself,  and  when  it  yields  to  the  more  profound  and  serious 
disease."  ♦ 

With  respect  to  hysteria,  we  are  told  by  Dr.  Mont- 
gomery, although  in  its  ordinary  or  slighter  forms,  it 
is  not  perhaps  properly  deserving  the  name  of  mental 
disturbance,  its  more  aggravated  conditions  are  so 
closely  allied  thereto,  that  it  must  be  extremely  diffi- 
cult to  draw^  the  line  of  distinction.  "  Cases  of  this 
kind,"  says  Dr.  Conolly,  "  approach  near  to  insanity  ; 
and,  indeed,  a  mind  subject  to  the  violent  agitations 
incidental  to  the  hysteric  constitution  cannot  be  con- 
sidered as  perfectly  sane  ; "  f  ^  state  of  which  Syden- 
ham has  given  so  admirable  and  graphic  a  descrip- 
tion, in  which  he  says,  the  patients  "  observe  no  mean 
in  anything,  and  are  constant  only  to  inconstancy  ;  so 
unsettled  is  their  mind  that  they  never  are  at  rest."  J 
Montgomery  says,  — 

"  Of  one  fact,  at  least,  my  own  experience  and  that  of 
others  afford  sufficient  evidence,  that  when  the  aggravated 
form  of  hysteria  prevails  throughout  pregnancy,  puerperal 
mania  is  much  to  be  apprehended. §  I  have  also  observed, 
in  not  a  few  instances,  that  women  who,  at  other  times,  have 
been  the  subjects  of  that  slight  form  of  mental  unsteadiness 
which  goes  by  the  name  of  extreme  nervousness,  and  is 
evinced  in  an  unreasonable  susceptibility  of  impressions 
from  slight  causes  affecting  their  moral  feelings,  but  without 
any  perceptible  lesion  of  the  intellectual  faculties,  and  con- 
stituting probably  the  simplest  form  of  moral  insanity,  have 

*  Manual  of  Psychologica]  Medicine,  p.  301. 
t  Cyclopaedia  of  Practical  Medicine,  ii.  p.  563. 
t  Swan's  Translation,  ed.  1769,  p.  414. 
5  Purrows,  loc.  cit.,  p.  378. 


IN   WOMEN.  137 

had  their  state  of  mind  greatly  improved  during  pregnancy; 
but  soon  after  the  termination  of  that  condition,  have  ex- 
hibited, for  a  time,  a  greater  degree  of  mental  disquiet  than 
was  habitual  with  them,  which,  however,  again  settled  down 
into  their  ordinary  state. 

•'I  desire  now  to  observe  that,  in  thus  noticing  some  of 
the  more  remarkable  phenomena  occasionally  displayed 
during  pregnancy,  it  is  not  intended  to  imply  that  such  are 
the  usual  concomitants  of  that  condition ;  on  the  contrary, 
most  of  them  are  to  be  considered  as  rare  occurrences,  some 
of  them  remarkably  so,  and  all  as  exceptions  to  the  general 
rule ;  but,  for  this  very  reason,  deserving  of  particular  notice, 
as  probably  connected  with  a  morbid  state  of  the  system, 
either  absolutely  existing  at  the  time,  though  perhaps  not 
otherwise  clearly  appreciable,  or  about  to  be  developed,  as 
in  the  case  I  have  already  related,  where  memory  of  the 
whole  time  of  pregnancy  was  a  complete  void;  my  object 
being  to  point  out  forcibly,  what  experience  seems  to  have 
fully  established,  that  during  pregnancy  the  system  is  in  a 
state  of  unusual  susceptibility;  the  activity  of  both  the  ner- 
vous and  circulating  systems  being  at  that  time  greatly 
exalted,  by  which  the  female  is  rendered  much  more  liable 
to  be  injuriously  affected,  even  by  ordinary  causes,  and  still 
more  so  by  any  of  a  more  impressive  kind."t 

The  peculiar  manifestations  which  demonstrate  this 
exaltation  of  the  nervous  system  are  of  the  most  varied 
character.  They  are  familiar  to  every  obstetrician, 
and  to  many  of  them  attention  has  been  called  by 
Montgomery.  Some  women,  for  instance,  are  much 
troubled  with  frightful  dreams  whenever  they  are 
pregnant.  Dr.  Lowder  used  to  relate  the  case  of  a 
lady  who  was  obliged  to  have  a  nurse  sitting  at  her 
bedside  all  night,  to  watch  her  countenance  while  she 

•  Signs  of  Pregnancy,  p.  41. 


138  REFLEX   INSANITY 

slept,  and  to  awaken  her  as  soon  as  she  perceived  hel 
exhibiting  distress  under  the  influence  of  her  dreamy 
terrors.  Disorder  of  the  ahmentary  canal,  disturbing 
the  already  irritated  nervous  system,  is,  probably,  the 
most  frequent  cause  of  this  affection ;  it  may  also  be 
induced  by  irregular  or  undue  circulation  of  blood  in 
the  brain ;  relief  has  been  obtained  by  acting  upon 
such  a  presumption,  administering  aperients,  and  ab- 
stracting blood  by  cupping  on  the  nape  of  the  neck. 

According  to  Beccaria,  there  is  a  peculiar  kind 
of  headache  accompanying  pregnancy,  which  he 
describes  as  an  acute  pulsating  pain  in  the  occipital 
region  ;  *  occupying  particularly  the  part  in  which 
Gall  places  the  organ  of  the  instinct  of  reproduction. 
"  This  pain,"  he  says,  "  is  accompanied  with  giddi- 
ness on  the  least  motion  of  the  head,  and  with  diffi- 
culty in  supporting  the  light ;  it  comes  on  suddenly, 
and,  continuing  for  some  time,  is  succeeded  by  an 
inclination  to  sleep."  f     It  is  often  perceived. 

There  is  another  variety  of  headache,  familiar  to 
all  who  are  conversant  with  the  symptoms  of  sick 
women,  as  almost  pathognomonic  of  uterine  disease. 
It  is  generally  attended  with  a  peculiar  and  almost 
indescribable  sensation  of  outward  pressure  at  the 
vertex,  and  was  excellently  described,  some  years  since, 

•  Annali  Universal,   de  MeA,    September,    1830;    Archives  G^n^rales  d« 
Medicine,  xxiv.  p.  443. 
t  Montgomery,  loc.  cit.,  p.  384. 


IN   WOMEN.  139 

by   Dr.   Tyler,   the    present    Superintendent  of  the 
McLean  Asylum.* 

Strange  appetites,  moreover,  or  longings,  as  they 
are  called,  and  antipathies,  are  well  known  as  frequent 
attendants  on  pregnancy  in  many  persons ;  some  of 
whom  will  long  to  eat  unusual,  and  even  revolting 
articles,  while  others,  immediately  after  conception, 
are  seized  with  an  unconquerable  aversion  to  species 
of  food  which  were  previously  particularly  agreeable 
to  them.     Montgomery  says,  — 

"  I  have  seen  several  well-marked  instances  of  this,  and, 
in  particular,  one  in  the  case  of  a  lady  who  assured  me  that 
she  always  knew  when  she  was  with  child,  by  feeling  a  vio- 
lent antipathy  for  wine  f  and  tea,  which,  at  other  times,  she 
took  with  pleasure.  I  had  an  opportunity  of  observing  the 
accuracy  of  this  indication,  in  the  successive  pregnancies 
of  the  lady  alluded  to.  A  patient  of  Dr.  Dewees  used  to 
consume  enormous  quantities  of  chalk  when  pregnant;  and 
Capuron  knew  a  woman  whose  principal  food  was  long 
pepper,  which  she  used  to  swallow  by  handfuls  ;  J  under  the 
same  circumstances,  one  patient  of  mine  eats  quantities  of 
cloves,  for  the  first  three  or  four  months ;  and  another  in- 
dulges with  equal  freedom  in  eating  dry  oatmeal. 

"  There  is  a  curious  and  interesting  coincidence  between 
such  facts  as  these,  and  others  not  unfrequently  observed  in 
certain  states  of  uterine  disturbance,  connected  with  sup- 
pressed or  deranged  menstruation ;  especially  about  the 
time  when  that  function  is  first  established,  when  it  is  not 
unusual  to  find  girls  eat  with  avidity  the  most  uninviting 

*  New  Hampshire  Journal  of  Medicine,  November,  1851,  p  62.  See  also  the 
Journal  of  the  Gynajcological  Society  of  Boston,  May,  1870,  p.  262. 

t  This  particular  aversion  was  expressly  noticed  by  Hippocrates  as  a  sign  of 
pregnancy,  "  viuum  odio  habent."    De  Infecundis,  Cap.  6. 

t  Trait^  des  Accouchemens,  p.  42. 


140  REFLEX    INSANITY 

substances,  such  as  cinders,  dry  mortar,  or  clay;  and  in  a 
case,  about  which  I  was  some  time  ago  consulted,  the  young 
lady  used  to  pick  the  bog-wood  out  of  the  grate  and  eat  it. 

"  This  morbid  state  of  the  appetite  did  not  escape  the  no- 
tice of  Ben  Jonson,  who  thus  alludes  to  it :  — 

*  She  can  cranch 
A  sack  of  small  coal,  eat  you  lime  and  hair, 
Soap,  ashes,  loam,  and  has  a  dainty  spice 
Of  the  green  sickness. '  * 

'♦  Such  caprices  of  appetite  may  at  first,  perhaps,  only 
excite  a  smile,  but  experience  appears  to  have  sufficiently 
shown  that  their  indulgence  cannot  always  be  permitted 
without  imminent  risk  of  injury  to  the  mother,  or  child,  or 
both."  t 

These  propensities,  in  their  essence  maniacal  and 
in  their  demonstratious  often  clearly  so,  have  received 
special  attention  from  anotlier  British  observer,  J  to 
whom,  however,  I  should  hardly  refer  at  this  time 
had  not  his  explanations  of  the  phenomena  in  ques- 
tion been  evidently  accepted  as  valid  by  a  noted 
psychologist.  Dr.  Forbes  Winslow,  from  whose  inter- 
esting though  somewhat  poetical  article  upon  woman 
in  her  psychological  relations,  I  shall  accordingly 
present  a  few  extracts. 

"The  modifications  of  the  appetite,  says  Dr.  Laycock, 
necessary  in  the  female  of  the  lower  animals,  for  the  proper 
nutrition  and  development  of  the  ovum  or  foetus,  are  occa- 
sionally reproduced  in  the  pregnant  human  female  as  morbid 
appetites. 

"  It  has  been  obseryed  by  naturalists  that  birds  will  eat 
lime  or  chalk  while  laying  —  obviously  that  the  shell  may  b'J 

*  The  Magnetic  Lady,  Act  I.  Sc.  x.  t  Montgomery,  pp.  278,  27^ 

t  Laycock :  Treatise  on  the  Nervous  Diseases  of  Women. 


IN    WOMEN.  141 

duly  formed ;  for,  if  hens  be  deprived  of  the  opportunity  of 
obtaining  it,  the  eggs  have  only  a  membranous  covering,  or 
an  imperfect  shell.  So,  also,  female  carnivorous  animals 
have  the  appetite  for  their  natural  food  more  ravenously  ex- 
cited during  utero-gestation  and  lactation,  to  the  same  end  : 
namely,  that  of  duly  perfecting  the  nutrition  of  the  young 
animal.  These  morbidly  excited  appetites  are  known  as 
'longings'  in  the  pregnant  woman,  and  in  the  young  un- 
married woman  as  pica  and  bulimia.  This  change  in  the 
appetites  has  always  attracted  popular  attention,  and  given 
rise  to  much  astonishment,  but  we  are  now  euabled  to  trace 
them  to  their  origin.  Dr.  Laj'cock  observes,  that  although 
during  pregnancy  some  good  wives  'long'  for  handsome 
dresses,  furniture,  &c.,  yet  these  longings  are  spurious,  since 
the  morbid  feelings  belong  exclusively  to  the  appetite  for 
food.  Ben  Jonson  notices  these  spurious  longings,  as  fol- 
lows :  — 

" '  Littleivit.  —  O  yes.  Win  :  you  may  long  to  see  as  well  as  to  taste,  Win :  as 
did  the  'pothecary's  wife,  Win,  that  longed  to  see  the  anatomy,  Win.  Or  the 
lady,  Win,  that  desired  to  spit  in  the  great  lawyer's  mouth,  after  an  eloquent 
pleading.'  —  Bartholomew  Fair,  Act  III.  Sc.  1. 

"Ben  Jonson,  indeed,  seems  to  have  had  some  experience 
in  this  form  of  morbid  appetite,  for  he  refers  to  it  again  and 
again  in  his  plays.  Thus,  in  Act  I.,  of  that  just  quoted,  he 
makes  the  same  character  say,  — 

"  '  Win,  long  to  eat  of  a  pig,  in  the  fair,  do  you  see,  in  the  heart  of  the  fair, 
tiot  at  Pye-comer.  Your  mother  will  do  anjrthing,  sweet  Win,  to  satisfy  your 
longing,  you  know ;  pray  thee,  long  presently,  and  be  sick  'o  the  sudden,  good 
Win,'  &c. 

"The  things  desired  in  this  ovarian  perversion  of  the  ap- 
petite are  sometimes  very  extraordinary,  and  outrageously 
absurd.  Dr.  Laycock  quotes  Dr.  Elliotson  as  mentioning 
in  his  lectures  that  a  patient  has  longed  for  raw  flesh  (the 
carnivorous  appetite),  and  even  for  live  flesh,  so  that  some 
have  eaten  live  kittens  and  rats.  Langius,  a  German  wri- 
ter, tells  a  story  of  a  woman  who  lived  near  Cologne,  who 
had  such  a  cannibalish  longing  for  the  flesh  of  her  husband, 


142  REFLEX    INSANITY 

that  she  killed  him,  ate  as  much  of  him  as  she  could  while 
fresh,  and  pickled  the  remainder.  Another  longed  for  a 
bite  out  of  a  baker's  arm.  More  marvellous  masticators 
than  the  case  described  in  the  play  of  'The  Magnetic  Lady,' 
from  which  we  have  already  quoted ;  although  Dr.  Laycock 
quotes  the  case  of  a  German  woman  who  would  eat  a  bon- 
bonniere  of  charcoal. 

"The  'dainty  spice  of  the  green-sickness*  is  known  by 
some  pathologists  under  the  term  of  '  Temper  Disease.'  It 
is  attended  by  the  impaired  digestion  and  defective  assimila- 
tion which  characterize  chlorosis,  and  by  the  most  extraor- 
dinary perversions  of  temper,  very  frequently  with  regard  to 
diet,  the  patient  persisting  in  a  system  of  starvation,  or  only 
taking  the  most  improper  food,  or  that  which  she  can  get  by 
stealth.  Here,  again,  we  trace  a  link  of  the  mysterious 
chain  which  connects  organism  together,  and  can  have  little 
doubt  that  this  form  of  psychological  change  is  due  to  a 
morbid  action  of  the  reproductive  organs,  such  as  occurs 
occasionally  in  pregnancy. 

"  There  are  other  alterations  in  the  mental  character  of 
women  belonging  to  this  class  of  perverted  instincts,  which 
are  of  greater  importance,  because  they  involve  the  social 
and  moral  relations.  The  hysterical  cunning  of  the  youhg 
female  is  traced  by  Dr.  Laycock  to  the  same  ovarian  source. 
Referring  to  the  development  of  certain  instincts  in  the  fe- 
male at  the  period  of  procreation,  and  when  the  care  of  off- 
spring is  the  great  end  of  life,  he  compares  the  artfulness  of 
the  lower  animals  with  this  hysterical  cunning,  and  attributes 
it -to  the  influence  of  the  ovaria  on  the  nervous  system.* 

"  He  also  observes,"  continues  the  reviewer,  "  that  astute- 
ness is  as  much  the  characteristic  of  woman  as  courage  is 
of  man,  but  that  these  characteristics  are  not  morbidly  de- 
veloped except  under  given  circumstances.  It  is  not  until 
puberty  that  these  peculiar  qualities  of  the  constitution  of 
woman  are  distinctly  brought  out;  and  in  brutes  it  is  only 
when  the  business  of  reproduction  is  carried  on,  that  this 
artfulness  is  so  exalted  as  to  rival  the  highest  attempts  of 

•  Joam.al  of  Psychological  Medicinr,  Jan.,  1851,  p.  31. 


IN    WOMEN. 


H3 


human  sagacity.  The  skill  they  display  in  the  choice  of  a 
secret  place  in  which  to  deposit  their  eggs  or  young,  and  the 
finesse  with  which  the  latter  are  protected  from  discovery  or 
injury,  are  well  known  to  the  most  inexperienced  student  of 
natural  history.  The  lioness,  for  example,  ferocious  and 
powerful  as  she  is,  when  she  fears  the  retreat  in  which  she 
has  placed  her  cubs  will  be  discovered,  will  hide  her  foot- 
marks, by  retracing  the  ground,  or  brushing  them  out  with 
her  tail.  When  the  young  female  suffers  from  irregular  ac- 
tion of  the  ovaria  on  the  system,  the  natural  astuteness  and 
quickness  of  perception  degenerate  into  mere  artfulness,  or 
monomaniacal  cunning;  and  it  is  to  this  morbid  influence 
of  the  ovaria  on  the  organ  of  the  mind,  that  Dr.  Laycock 
attributes  the  extraordinary  instances  of  monomaniacal  cun- 
ning in  females,  on  record.  He  observes,  on  this  head,  'Of 
all  animals,  woman  has  the  most  Jlcute  faculties;  and  when 
we  consider  how  much  these  ;nay  be  exalted  by  the  influence 
of  the  reproductive  organs,  there  is  not  much  ground  for 
surprise  at  the  grotesque  forms  which  cunning  assumes  in 
the  hysterical  female,  although  they  have  cauvsed  much 
speculation  and  astonishment.  Insane  cunning  is  usually 
exhibited  in  attempts  at  deception,  but  occasionally  in  a 
propensity  to  steal,  or  rather  to  steal  slyly.  It  may  be  re- 
marked that,  when  it  occurs,  it  may  be  as  much  a  symptom 
of  hysteria  as  any  corporeal  affection  whatever.  It  is  a  true 
monomania,  and  is  most  likely  to  occur  in  the  female  who 
is  hysterical  from  excess  of  sexual  development — one  pos- 
sessing the  utmost  modesty  of  deportment  and  grace  of  figure 
and  movement,  for  the  modesty  itself  springs  out  of  that 
feminine  timidity  to  ivhich  I  have  just  alluded.  Sly  stealing, 
however,  is  most  frequently  observed  in  pregnant  women.' 
The  Italics  in  the  above  quotation  are  our  own,"  says  Dr. 
Winslow,  "as  we  wish  to  direct  the  reader's  special  atten- 
tion to  the  impox'tant  principle  pointed  out  by  Dr.  Laycock. 
The  propensity,  in  such  case,  is  dependent  solely  on  the  ex- 
citement of  the  nervous  system  \>y  the  ovaria;  hence  it  is 
that  when,  in  consequence  of  an  active  condition  of  those 
structuies,  the  graces  peculiar  to  the  feminine  character  are 


1^14  REFLEX    INSANITY 

peculiarly  developed,  and  gentleness,  modesty,  and  timidity 
are  prominent  characteristics,  often  in  those  identical  cases 
it  is,  that  there  is  this  morbid  excitation  of  the  instinct  of 
artfulness  or  cunning;  and  it  is  these  endowments  which 
explain  the  influence  that  hysterical  girls  have  upon  all  that 
come  near  them,  and  which  is  really  astonishing;  parents, 
women,  physicians,  all  yielding  to  them.  It  is  also  the 
marked  excitation  of  this  sexual  artfulness,  which  renders 
nugatory  all  the  experiments  and  labors  of  those  mesmer- 
ists, whose  principal  subjects  are  young  females  or  youths 
about  the  age  of  puberty.  Psychologists,  practically  ac- 
quainted with  this  subject,  can  place  no  reliance  upon  the 
statements  of  the  hysterical  females  upon  whom  mesmerists 
experiment,  however  well  educated,  gentle,  good,  and  truth- 
loving  they  may  be  naturally,  and  really  are  in  all  other 
matters.  Physicians  have  recorded  numerous  instances  of 
strange  and  motiveless  deceptions,  thefts,  and  crimes  prac- 
tised by  young  women,  even  by  ladies  of  unexceptionable 
morals,  excellent  education,  and  high  rank.  Fasting  wo- 
men, ecstatica,  sly  poisoners,  pilfering  lady-thieves,  &c., 
present  examples  of  this  kind;  particular  instances  we  need 
not  mention,  as  they  may  be  found  in  most  works  on  hyste- 
ria, and  often  occupy  a  niche  in  the  newspapers.  When 
cunning  is  combined  with  a  morbid  excitation  of  the  pro- 
pensity to  destroy,  such  as  is  manifested  in  the  females  of 
brutes,  the  effect  is  sometimes  dreadful,  and  is  seen  in  the 
perpetration  of  secret  murders  by  wholesale  poisoning,  or  in 
secret  incendiarism ;  and  if  other  natural  instincts  be  per- 
verted, the  objects  of  woman's  warmest  and  most  disinter- 
ested affections  may  perish  by  her  hand.  It  is  a  singular 
fact  in  natural  history,  and  remarkably  illustrative  of  our 
views,  that  parturient  domestic  animals  sometimes  suffer 
from  the  same  morbid  condition  of  the  nervous  system  as 
the  human  mother,  and  they  also  destroy  their  offspring. 
Thus,"  as  we  have  already  had  pointed  out  by  Mayhew, 
"cats,  sows,  and  bitches  have  been  known  to  eat  their 
litter;  cows  to  butt  their  calves  to  death,  hens  to  chase  their 
chickens,  &c. 


IN    WOMEN.  145 

"When  cunning  is  combined  with  a  morbid  state  of  the 
temper,  the  misery  inflicted  upon  domestic  peace  is  mex- 
pressible.  The  ingenuity  in  malice  and  falsehood  displayed 
by  the  patient,  is  most  extraordinary;  so  extraordinary,  in- 
deed, that  it  is  never  credited  until  it  is  experienced.  Cases 
are  by  no  means  infrequent  in  which  the  sufferer  from  thi* 
sad  derangement  is  the  most  intellectual  and  most  amiable 
of  the  family;  beloved  by  all,  respected,  almost  worshipped. 
Hence,  when,  after  numerous  struggles  to  repress  them,  the 
propensities,  excited  into  such  fearful  and  almost  super- 
natural activity  by  the  ovarian  irritation,  burst  forth  beyond 
all  control,  and  the  pet  of  the  family  is  seen  to  be  the  op- 
posite, morally,  in  every  respect  to  what  she  had  been,  — 
irreligious,  selfish,  slanderous,  false,  malicious,  devoid  of 
afl'ection,  thievish  in  a  thousand  petty  ways,  bold,  may  be 
erotic,  self-willed,  and  quarrelsome  ;  the  shock  to  the  family 
circle  and  friends  is  intense ;  and  if  the  case  be  not  rightly 
understood,  great,  and  often  irrepai-able  mischief  is  done  to 
correct  what  seems  to  be  vice,  but  is  really  insanity. 

"  Perhaps  in  the  whole  range  of  psychology  there  is  no 
subject  so  deeply  interesting  as  this;  for  it  is  in  so-called 
moral  insanity  that  man's  spiritual  and  moral  nature  is  the 
most  awfully  and  most  distressingly  subjected  to  his  cor- 
poreal frame.  It  is  a  disease,  undoubtedly,  much  more 
frequent  in  the  female  sex  than  in  man."  * 

Dr.  Montgomery  says,  — 

"  Dr.  Harvey  mentioned  the  case  of  a  lady  who,  whenever 
she  was  pregnant,  became  affected  with  the  most  uncon- 
trollable passion  for  building;  this  had  taken  place  several 
times,  and  always  subsided  when  pregnancy  ceased.  A 
marked  change  in  the  temper  is  very  commonly  observed, 
so  that  a  woman  who  was,  under  ordinary  circumstances, 
extremely  mild  and  sweet-tempered,  immediately  becomes, 
when  pregnant,  irritable  and  capricious,  an  effect  which  in 
some  women  attends  each  recurrence  of  pregnancy."  t 

*  Journal  of  Psychological  Medicine,  January,  1851,  pp.  31,  43. 

♦  Loc.  cit.,  p.  278. 

10 


146  REFLEX    INSANITY 

These  are  clearly  and  distinctly,  to  the  extent  to 
which  each  of  them  goes,  cases  of  a  monomaniacal 
character;  which  character,  in  itself  considered,  is 
not  affected  by  the  possibility  of  the  affection  in  some 
cases  being  intermittent,  paroxysmal,  or  periodical, 
while  in  others  it  is  chronic  and  persistent.  There 
are  other  abnormal  manifestations,  even  of  special 
sense,  of  whose  occurrence  abundant  evidence  can  be 
aflbrded. 

There  is  a  simulation  of  disease  which  occasion- 
ally accompanies  pregnancy,  and  depends  apparently 
on  disturbance  of  the  nervous  influence,  which  some- 
times very  remarkably  afiects  the  functions  of  some 
of  the  organs  of  the  ejxternal  senses,  in  which  no 
appreciable  organic  change  can  be  at  the  time  dis- 
covered ;  and  that  none  such  does  really  take  place, 
seems  sufficiently  evident  from  the  fact  that  the  affec- 
tion lasts  only  during  gestation.  Thus,  instances  of 
temporary  amaurosis  induced  by  pregnancy  are  by 
no  means  uncommon.*     Dr.  Montgomery  says,  — 

*'  I  saw  a  lady  thus  affected;  she  could  see  certain  objects 
distinctly,  as  a  line  drawn  on  paper;  others  appeared  con- 
fused, and  some  she  could  hardly  discern  at  all;  occasion- 
ally she  imagined  she  saw  objects  which  were  not  present, 
as  a  person  crossing  the  room,  or  flower-pots,  or  bunches 
of  flowers  on  her  table,  when  nothing  of  the  sort  was  there. 
Salmutius  relates  a  case  in  which  a  lady  became  blind  every 
time  she  was  pregnant,  and  recovered  her  sight  as  soon  as 

*  Good :  Study  of  Medicine,  iv.  p.  247 ;  Cooper :  Surgical  Dictionary  irt. 
Amaurosis. 


IN    WOMEX.  147 

she  lay  in.*  Beer  saw  a  young  Jewess,  who  at  the  very  be- 
ginning of  her  first  three  pregnancies,  which  followed  each 
other  quickly,  regularly  became  amaurotic,  and  continued 
blind  till  after  delivery ;  but  on  the  third  occasion  she  did 
not  recover  her  sight.f  Chambon  ascribes  these  affections 
to  plethora;  but  such  an  explanation  is  scarcely  consistent 
with  the  occurrence  of  amaurosis  from  protracted  or  undue 
laetation,  when  the  constitution  is  in  a  state  of  great  debility 
and  exhaustion  ;  two  well  marked  instances  of  which  I  saw 
in  two  sisters,  who  quickly  recovered  their  sight  by  weaning 
their  children.  Dr.  Mathews,  of  Moate,  has  just  informed 
me  of  the  case  of  a  lady  who,  when  five  months  pregnant, 
for  the  first  time  sustained  total  loss  of  voice,  which  she  re- 
covered at  the  time  of  her  labor.  Gardien  notices  this  part 
of  our  subject  fully,  and  mentions  a  variety  of  affections 
which  I  have  not  met  with. J  Dr.  Bennewitz  has  detailed 
the  particulars  of  a  case,  in  which  a  young  woman  was,  in 
three  successive  pregnancies,  afiected  with  diabetes  mellitus ; 
which,  each  time,  completely  ceased  on  delivery,  but  again 
returned  when  she  became  pregnant."  § 

These  physical  derangements,  of  reflex  and  uterine 
causation,  are  sometimes  extreme.  Thus  it  is  not  un- 
usual, during  the  existence  of  pregnancy,  to  find  the 
power  of  one  or  both  of  the  lower  limbs  more  or  less 
impaired  ;  and,  in  some  few  rare  instances,  they  have 
bcome  partially  or  completely  paralytic,  and  even 
hemiplegia  has  been  obsei-ved.    Montgomery  says, — 

"  To  what  degree  the  mere  enlargement  of  the  uterus  is 
the  agent  in  the  production  of  such  a  state  (by  mechanical 
pressure)  seems  very  doubtful,  especially  as  we  som(;times 

•  Cent.  in.  Obs.  27. 
t  Lchre  von  den  Augenkrankheiten. 
t  Tr.T.te  des  Accouchemens,  i.  p.  437,  and  ii.  76. 

§  Osam:  Clinical  Report  for  1823;  Edinburgh  Medical  Journal,  xxx.  p.  217 
Mortgomery,  loc.  cit.,  p.  4.7. 


148  REFLEX    INSANITY 

find  the  paralysis  affecting  the  upper  extremities;*  the 
blood  drawn  under  such  circumstances  has  been  observed 
to  present  highly  inflammatory  characters;  but  whatever 
measures  may  be  adopted,  the  affection  is  never  perfectly 
removed  until  after  delivery,  from  which  it  would  appear  to 
depend  on  cerebral  disturbance,  originating  probably  in 
uterine  irritation,  and  referable  to  the  state  of  pregnancy  as 
its  specific  cause."  f 

Of  course  such  cases  are  to  be  distinguished  from 
those  of  paralysis  occurring  during  or  after  labor,  in 
consequence  of  apoplectic  convulsions,  or  from  undue 
or  long-continued  pressure  upon  the  pelvic  nerves  by 
the  foetal  head. 

The  evidence  that  I  have  now  presented  proves 
more  than  that  the  state  of  pregnancy  is  one  subject 
to  grave  mental  and  physical  derangement,  giving 
rise  to  serious  anxieties,  and  requiring  judicious  treat- 
ment. It  proves,  also,  that  at  the  foundation  of  the 
whole  matter  lies  an  excited  uterus.  The  irritation 
that,  during  pregnancy,  may  coexist,  as  a  normal  and 
physiological  state,  with  the  usual  or  improved  health, 
may,  in  other  cases,  assuming  a  pathological  type,  or 
in  the  presence  of  pathological  adjuncts,  cause  the 
inception  or  development  of  severe  disease.  In  other 
words,  the  tendency  to  reflex  derangement,  whether 
of  body  or  mind,  usually  attending  uterine  disturb- 
ance, but  also  usually  controlled  during  pregnancy  by 
the  vis   medicatrix  of  impregnation,    may   at   times 

•  Edinburgh  Monthly  Journal,  xii.  p.  492. 
t  Loc.  cit.,  p.  5. 


IN   WOMEN.  149 

during  this  period  assume  its  primal  sway,  and  pro- 
duce effects,  under  other  circumstances  naturally  to 
be  expected. 

If  we  change  the  premises,  the  same  result  obtains. 
I  have  assumed  the  excited  uterus  as  a  natural  cause 
of  reflex  disease,  as  is  proved  by  its  conduct  at  times 
other  than  pregnancy,  and  have  shown  that  the  dis- 
eases of  pregnancy  are  but  the  special  diseases  of 
other  times  allowed  to  exhibit  themselves  here.  Let 
us  now  shift  the  scenes  of  proof,  and  assuming  preg- 
nancy, however  occasionally  permitted  to  occur,  as 
the  normal  condition  of  the  adult  woman,  and  its 
processes  uninterfered  with,  and  as  usually  presenting 
themselves  to  be  strictly  physiological  in  their  char- 
acter, we  will  compare  its  diseases,  physical  and 
mental,  with  the  special  affections  of  women  occur- 
ring at  other  times.  They  are  found  to  be  nearly 
identical  in  type,  in  detail,  in  their  general  course 
and  result :  a  similarity  of  effect  argues  an  identity 
of  cause.  Whichever  horn  of  the  dilemma  is  then 
selected,  its  point  is  the  same.  If  an  excited  uterus 
causes  the  derangements  of  pregnancy,  so  it  does 
those  of  other  special  times  and  seasons.  If  an.  ex- 
cited uterus  causes  the  latter,  it  is  by  the  same  mech- 
anism and  same  reflex  causation  as  that  by  which 
the  former  are  occasioned. 

As  to  puberty,  for  instance  :  I  will  quote  a  worii 
from  Dr.  Ray. 


150  REFLEX   INSANITY 

"  That  the  evolution  of  the  sexual  functions  is  very  often 
attended  by  more  or  less  constitutional  disturbance,  espe- 
cially in  the  female  sex,  is  now  a  well-established  physio- 
logical truth.  The  shock  seems  to  be  felt  chiefly  by  the 
nervous  system,  which  experiences  almost  every  form  of  ir- 
ritation, varying  in  severity  from  the  slightest  hysterical 
symptoms  to  tetanus,  St.  Vitus's  dance,  and  epilepsy.  And 
when  we  bear  in  mind,  also,  that  general  mania  is  some- 
times produced  by  this  great  physiological  change,  it  cannot 
be  deemed  an  extraordinary  fact  that  partial  mania,  excit- 
ing to  acts  of  incendiarism  or  murder,  should  be  one  of  its 
effects."  ♦ 

Just  as  puberal  mania  may  thus  be  produced,  so 
may  there  occur  the  first  explosion  at  any  other  of 
the  periodic  crises,  of  longer  or  shorter  interval,  to 
which  we  have  seen  woman  is  constantly  liable.  The 
climacteric  invasion  of  insanity  has  lately  been  studied 
by  Dr.  Francis  Skae,  formerly  attached  to  the  Royal 
Asylum  at  Morningside,t  and  it  is  to  be  hoped  that 
we  may  soon  have  memoirs  upon  each  of  the  other 
developmental  types  to  which  I  have  already  alluded. 

I  have  now  shown  that  both  a  priori^  and  from 
the  evidence  of  experts  in  insanity,  there  is  reason  to 
believe  that  their  sex  lies  at  the  foundation,  physio- 
logically and  pathologically,  of  much  of  the  mental 
derangement  that  occurs  in  women.  I  am  well  aware 
that  the  work  has  been  but  imperfectly  performed. 
Had  space  and  a  fair  allowance  for  the  patience  of 
the  Association  permitted,  I  should  have  presented 

•  Medical  Jurisprudence  of  Insanity,  p.  aoo. 

t  Edinburgh  Medical  Journal,  Feb.,  1865,  p.  703. 


IN  WOMEN.  151 

much  additional  proof  that  I  am,  at  present,  com- 
pelled to  withhold. 

Negative  evidence,  no  matter  what  its  amount  or 
from  what  quarter  aflbrded,  should  not,  I  would  re- 
spectfully submit,  be  allowed  to  weigh  against  the 
positive  proof  that  I  have  afforded ;  yet  the  argu- 
ments that  can  alone  be  brought  to  disprove  my  posi- 
tion are  strictly  and  merely  negative  in  their  charac- 
ter. It  will  be  sufficient  if  I  refer  to  merely  one  or 
two  of  them.  From  an  example  we  may  understand 
its  class. 

It  has  been  stated  by  several  writers,  —  I  have  al- 
ready quoted  Dr.  Earle's  opinion  upon  the  subject,  — 
that  the  regular  occurrence,  absence,  or  suppression 
of  the  catamenia  seems  in  many  cases  to  have  made 
no  difference  as  to  the  causation,  continuance,  or  cure 
of  insanity  in  women,  and  that  therefore  the  uterus 
and  ovaries  are  proved  incapable  of  exerting  any  ap- 
preciable influence  as  an  agent  in  the  production  of 
the  mental  disease.  The  error  that  is  here  present  is 
an  evident  one  :  it  is  in  considering  that  in  all  uterine 
or  ovarian  diseases  there  must  be  derangement  of  a 
single  function,  that  of  menstruation,  or  that  the  pres- 
ence and  partial  or  complete  performance  of  this  func- 
tion argues  uterine  health.  Such  an  argument  only 
proves  most  lamentable  ignorance,  even  of  the  most 
common  and  simplest  of  the  diseases  of  women,  and 
of  which  the  youngest  medical  student  of  the  present 
day  vyould  be  ashamed. 


152  REFLEX    INSANITY 

Again,  it  must  not  be  forgotten  that  the  diseases 
special  to  women  are  now  recognized  to  embrace  a 
vast  variety  of  simple  and  complex  lesions,  equalHng 
in  number,  if  not  excelling,  those  of  any  other  organ 
or  system  of  organs  in  the  body.  The  wise  physician 
of  old  was  not  far  wrong  in  his  judgment :  "  What  is 
woman  ?  Disease,  says  Hippocrates."  *  The  absence 
of  one  affection,  of  whatever  class,  in  any  given  pa- 
tient, is  no  evidence  that  another  may  not  exist.  Am 
I  wrong,  then,  in  advising  more  careful  examinations 
than  are  commonly  made,  even  in  general  practice? 

Still  further,  it  has  been  asserted,  that  because  many 
insane  women  make  no  complaint  of  pelvic  pain,  we 
ought,  from  that  fact,  to  take  for  granted  the  non- 
existence of  uterine  disease.  This  statement  would 
hardly  be  made  were  it  recollected  —  for  every  medi- 
cal man,  however  long  retired  from  active  practice, 
must  once  have  known  —  that  even  among  sane  pa- 
tients cases  are  not  so  very  uncommon  of  advanced 
and  decided  uterine  disease  when  the  only  pains  pres- 
ent are  reflex,  and  exhibited  merely  as  distant  neural- 
gias of  the  back,  face,  breast,  or  other  location.  In- 
deed, I  may  state  that  I  have  seen,  in  quite  a  number 
of  instances,  the  uterus  nearly  destroyed  by  malignant 
disease,  without  a  trace  of  the  lancinating  pain  that 
authors  have  too  much  insisted  upon  as  necessary, 
however  generally  pathognomonic  when  it  does  exist, 

*  Michelet:  L' Amour. 


IN    WOMEN.  153 

and  the  patient  hardly  aware  of  any  local  discomfort. 
That  such  cases  do  occur  in  the  sane,  only  strengthens 
the  argument  I  have  elsewhere  dwelt  upon,  quoting 
Bucknill  and  other  authorities  ;  that  while  the  pecul- 
iar tolerance  of  pain,  so  often  observed  in  the  insane, 
is  now  allowed  frequently  to  veil  the  existence  of 
phthisis  and  similar  forms  of  organic  disease,  just  as 
it  does  of  wounds  and  injuries,  so  must  it  be  granted 
that  at  times  there  may  exist  and  progress  any  and 
every  form  of  uterine  and  pelvic  lesion  without  its 
coming  to  the  knowledge  of  the  physician  or  asylum 
superintendent,  unless  he  suspect  its  occurrence,  and 
search  therefor. 

As  a  single  instance  from  many  that  might  be  given, 
I  append  a  statement  by  Dr.  Tuke,  attached  to  the 
Royal  Lunatic  Asylum  at  Morningside,  near  Edin- 
burgh. In  presenting  to  the  Edinburgh  Obstetrical 
Society,  at  its  meeting  in  January,  1865,  specimens 
of  fibroid  tumor  and  polypus  of  the  uterus,  removed, 
post-mortem,  from  a  woman  who  had  been  in  the 
asylum  for  twenty  years,  without  ever  making  com- 
plaint of  pelvic  disturbance,  this  gentleman  remarks,  — 

"  I  was  not  aware  of  the  existence  of  the  tumor  until  I 
examined  her  amongst  other  patieuts,  making  a  careful  in- 
vestigation into  the  bodily  health  of  all  the  old  inmates, 
with  the  view  of  discovering  diseases  which  are  liable  to  lie 
latent  in  the  insane,  to  an  extent  hardly  to  be  credited  by 
any  but  those  accustomed  to  their  treatment."  * 

•  Edinburgh  Medical  Journal,  March,  1865,  p.  857. 


154  REFLEX    INSANITY 

And,  finally,  1  have  been  told  by  some  gentlemen, 
that  because  many  women  have  disease  of  the  uterus, 
detected  during  life,  without  insanity,  and  by  others, 
that  because  at  autopsies  of  sane  patients,  similar 
disease,  undetected  during  life,  because  unlooked  for, 
has  been  discovered ;  so  must  it  therefore  be  ad- 
mitted, that  it  is  impossible  that  diseased  conditions 
of  the  pelvis  and  of  the  brain  can  have  any  depend- 
ence upon  each  other.  Upon  just  such  absurdities  as 
these  —  for  I  can  honestly  apply  to  them  no  milder 
epithet  —  have  many  of  the  dogmas  of  psychologists 
been  founded.  As  well  might  it  be  asserted,  that  be- 
cause some  persons  with  musket  wounds  have  recov- 
ered, therefore  a  bullet  never  kills  ;  or,  because  in 
some  others,  as  in  the  late  eminent  geologist,  Hugh 
Miller,  for  instance,  extreme  cerebral  disorganization 
has,  for  a  while,  coexisted  with  apparent  mental  in- 
tegrity, that,  therefore,  such  disorganization  is  the 
normal  condition  of  the  brain,  or  can  never  be,  at 
any  rate,  the  cause  of  mental  disturbance.  And  yet 
it  is  by  just  such  baseless  objections,  that  gentlemen, 
professing  to  seek  only  the  advance  of  medicine  and 
the  cure  of  patients,  have  endeavored  to  prevent  a 
more  rational  treatment  of  insane  women  than  that 
now  generally  obtaining. 

There  are  many  questions  directly  presenting  them- 
selves in  this  connection,  interesting  equally  in  their 
practical  and  their  scientific  relations,  upon  which  I 


IN  WOMEN.  155 

have  much  to  say,  but  whose  discussion  I  must  defer 
to  another  occasion.  Such,  among  others,  are  the 
following :  — 

1.  The  effect  of  celibacy,  of  marriage,  of  widow- 
hood, as  causing  insanity  in  women. 

2.  The  transmissibility  of  insanity  as  an  inheritance 
by  the  mother,  as  compared  with  it  by  the  father. 

3.  The  occurrence  of  uterine  disease  in  the  mother, 
as  rendering  the  transmission  of  any  family  taint  of 
insanity  more  probable  to  her  offspring. 

4.  The  frequency  of  organic  cerebral  disease  in  in- 
sane women  as  compared  with  it  in  insane  men.* 

5.  The  epidemics  of  Tarentism,  convulsions,  sui- 
cide, exhortation,  &c.,  which,  occurring  among  fe- 
males, have  at  times  so  vexed  the  religious  and  pro- 
fane worlds. 

6.  The  special  propensities  of  invalid  women  to 
breach  of  the  law  or  of  propriety,  as  in  the  so-called 
pyromania,  klepto-,  dipso-,  erotomania ;  whether  this 
last  be  for  a  real  or  imaginary  object,  and  their  re- 
sponsibility therefor. 

7.  The  possibilities  of  a  longer  incubation  of  in- 
sanity, from  special  causes,  in  invalid  women  than 
would  probably  be  thought  credible. 

8.  The  periodicity  of  insanity  in  women,  and  the 

*  *■  Female  insanity  is  in  a  large  proportion  of  cases  merely  a  reflex  disturbance 
of  the  brain.  Insanity  in  men  much  more  extensively  involves  cerebral  lesion, 
and  their  mortality  is  proportionately  increased. "  Workman  :  Toronto  Report, 
i860  ;  American  Journal  of  the  Medical  Sciencesi  April,  1863,  p.  437. 


156  RKFLKX    INSANITY 

various  lengths  of  the  attack  and  the  interval ;  in 
some  instances  bounded  by  a  single  catamenial  peri- 
od, in  others  by  the  space  of  gestation,  of  lying-in,  of 
lactation,  or  the  whole  cycle  of  uterine  life,  from  pu- 
berty to  the  final  climacteric. 

9.  The  time  of  development  or  explosion  of  an 
hereditary  predisposition  to  insanity  ;  its  frequent  co- 
incidence with  a  special  epoch  in  woman's  life. 

10.  Epilepsy  in  women,  with  or  without  the  addi- 
tion of  decided  insanity,  or  its  previous  existence  as 
a  family  taint,  and  tlie  legal  responsibilities  of  female 
epileptics. 

I  had  prepared  from  my  own  note-books  the  histo- 
ries of  quite  a  number  of  cases,  illustrating  several 
of  the  special  points  now  indicated,  which  I  had  in- 
tended here  to  present,  in  connection  with  the  very 
interesting  series  published  not  long  since  by  Dr. 
Azam,  physician  to  the  asylum  for  insane  women  at 
Bordeaux ;  but  my  paper  is  already  so  long  that  I 
must  omit  them.  I  cannot,  however,  refrain  from 
quoting  the  last  of  Dr.  Azam's  conclusions,  so  com- 
pletely does  it  coincide  with  my  own  conviction  and 
my  own  experience. 

"  Every  other  treatment  than  physical  will  prove  useless 
so  long  as  the  organic  lesion  persists,  and  this  will  have  so 
much  the  greater  chance  of  being  effectual  as  it  is  resoi-ted 
to  at  a  time  approaching  the  commencement  of  the  dis- 
ease." * 

*  De  la  folic  sympathique  provoqu^e  et  entretenue  par  les  16sions  de  I'lit^rui 
et  de  ses  annexes. 


IN  WOMEN.  157 

VIII.  —  Indications  of  Treatmentv 

My  remarks,  present  and  past,  upon  the  causation 
of  insanity  in  women  have  been  elicited,  as  will  long 
since  have  been  perceived,  by  the  need,  as  it  seems 
to  me,  of  urging  upon  the  profession  a  more  rational 
treatment,  in  public  and  private  practice,  of  female 
lunatics.  My  views  upon  the  subject  are  not  the  re- 
sult of  any  hasty  and  ill-based  impression,  but  they 
are  matured,  and  from  somewhat  extensive  observa- 
tion. Without  the  slightest  presumption,  I  think  I 
may  here  say  that  I  know  whereof  I  do  affirm.  I 
cannot  at  this  time  go  into  the  detail  that  I  would 
gladly  do,  and  that  I  have  intended  doing  at  no  long 
subsequent  period ;  but  I  shall  at  least  show,  as  I 
think  indeed  I  have  already  done,  that  the  field  now 
endeavored  to  be  opened  to  the  practical  purposes  of 
the  profession  is  one  that,  though  hitherto  neglected, 
is  yet  one  of  the  most  fruitful  in  medicine. 

As  has  hitherto  been  done  in  this  communication,  I 
shall  endeavor  to  present  the  little  I  have  time  to  say 
concerning  treatment,  through  the  language  of  super- 
intendents themselves. 

An  author  whom  as  yet  I  have  hardly  referred  to. 
Dr.  Conolly,  of  the  asylum  at  Hanwell,  while  taking 
the  general  ground  of  non-restraint,  seems  to  have 
been  struck  by  the  eminently  sad  condition,  under 
the  best  of  care,  of  lunatic  women  as  compared  with 


158  REFLEX   INSANITY 

lunatic  men.  I  cannot  better  introduce  the  little  I 
can  say  in  this  especial  connection,  than  by  the  fol- 
lowing extract.     Dr.  Conolly  says,  — 

•'The  precise  condition  of  the  brain  in  different  patients 
is,  it  has  been  acknowledged,  as  little  known  as  the  mode 
and  nature  of  its  actions  in  health.  The  manner  in  which 
its  functions  are  interrupted  or  disordered  in  insanity,  lies 
in  a  region  beyond  the  reach  of  man's  senses,  and  seems 
scarcely  a  legitimate  object  for  strictly  philosophical  imagi- 
nation, unaided  by  any  means  of  appreciating  it,  and  lead- 
ing merely  to  '  wandering  thoughts  and  notions  vain.'  But 
the  connection  of  these  actions  with  material  organs,  and 
their  evident  sympathy  with  the  body  in  health  and  in  dis- 
ease, impart  certain  resources  to  the  physician,  who,  if  he 
can  only  act  directly  on  the  mind  within  narrow  limits,  finds 
that  he  can  extensively  and  powerfully  influence  it  by  sedu- 
lous attention  to  the  state  of  the  temple  in  which,  in  this 
condition  of  existence,  it  is  enshrined."  * 

Let  us  see  what  until  very   lately  has  been  this 

"  sedulous  attention  to  the  state  of  the  temple  of  the 

mind,"  so  justly  deemed  necessary  by  Dr.  Conolly. 

I  shall  first  quote  from  an  official  English  report  of 

but  a  few  years  ago,  with  the  simple  comment  that 

what  then  existed  in  Great  Britain,  still  exists,  to  our 

disgrace,  in  many  places  in  this  country. 

"  In  one  of  the  cells  for  the  women,  the  dimensions  of 
which  were  eight  feet  by  four,  and  in  which  there  was  no 
table,  and  only  two  wooden  seats,  we  found  three  females 
confined.  There  was  no  glazing  to  the  window,  and  the 
floor  of  the  place  was  perfectly  wet  with  urine.  The  two 
dark  cells  which  joined  the  cell  used  for  a  day-room,  are  the 
sleeping  places  for  these  three  unfortunate  beings.     Two  of 

*  Treatment  of  the  Insane,  p.  164. 


IX    WOMEN.  159 

them  sleep  in  two  cribs  in  one  cell.  The  floor  in  the  cell 
with  two  cribs  was  actually  reeking  wet  with  urine,  and  cov- 
ered with  straw  and  filth.  There  is  no  window,  and  no 
place  for  light  or  air  except  a  grate  over  the  doors."  ♦ 

Ten  years  later  than  the  date  of  the  report  from 
which  the  above  is  quoted,  it  was  my  fortune  to  be 
residing  in  Scotland,  when  its  lunatic  asylums,  public 
and  private,  were  subjected  to  the  official  scrutiny 
that  had  been  instigated  by  Miss  Dix.  The  descrip- 
tions already  given  and  to  follow  are  in  no  respect  an 
exaggeration  of  what,  in  many  quarters,  was  found 
to  exist.  Among  the  foremost  in  promoting  that 
investigation  was  my  instructor,  the  late  Professor 
Simpson  ;  and  it  was  the  facts  that  then  came  to  my 
knowledge,  that  first  called  my  attention  to  the  ne- 
cessity of  more  thoroughly  studying  the  causation 
and  treatment  of  insanity  in  women.  I  will  present 
a  true  picture  from  an  unbiassed  observer. 

"The  first  common  room  you  examine,  measuring  twelve 
feet  long  by  seven  wide,  with  a  window  which  does  not  open, 
is  [perhaps]  for  females.  Ten  of  them,  with  no  other  cov- 
ering than  a  rag  round  the  waist,  are  chained  to  the  wall, 
loathsome  and  hideous,  but,  when  addressed,  evidently  re- 
taining some  of  the  intelligence,  and  much  of  the  feeling, 
which,  in  other  days,  ennobled  their  nature.  In  shame  or 
sorrow  one  of  them  perhaps  utters  a  cry ;  a  blow,  which 
brings  the  blood  from  the  temple,  the  tear  from  the  eye, — 
an  additional  chain,  a  gag,  and  an  indecent  or  contemptuous 
expression,  produce  silence.  And  if  j'ou  ask  where  these 
creatures  sleep,  you  are  led  to  a  kennel  eight  feet  square, 

*  Report  of  the  English  Commissioners  in  Lunacy  for  1844. 


l6o  REFLEX    INSANITY 

with  an  unglazed  air-hole  eight  inches  in  diameter;  in  this, 
you  are  told,  five  women  sleep.  The  floor  is  covered,  the 
walls  bedaubed,  with  filth  and  excrement :  no  bedding  but 
wet,  decayed  straw  is  allowed ;  and  the  stench  is  so  insup- 
portable, that  you  turn  away,  and  hasten  from  the  scene."  ♦ 

Dr.  Conolly  says,  — 

*'  Indeed,  it  would  almost  seem  as  if,  at  the  period  from 
the  middle  to  near  the  end  of  the  last  century,t  the  super- 
intendents of  the  insane  had  become  frantic  in  cruelty,  from 
the  impunity  with  which  their  despotism  was  attended. 
Some  of  the  German  physicians  meditated  even  romantic 
modes  of  alarm  and  torture;  they  wished  for  machinery,  by 
which  a  patient,  just  arriving  at  an  asylum,  and  after  being 
drawn  with  frightful  clangor  over  a  metal  bridge  across  a 
moat,  could  be  suddenly  raised  to  the  top  of  a  tower,  and  as 
suddenly  lowered  into  a  dark  and  subterranean  cavern;  and 
they  avowed  that  if  the  patient  could  be  made  to  alight 
among  snakes  and  serpents  it  would  be  better  still.  People 
not  naturally  cruel  became  habituated  to  severity,  until  all 
feelings  of  humanity  were  forgotten.  I  used  to  be  aston- 
ished, even  seventeen  years  ago,  to  see  humane  physicians 
going  daily  round  the  wards  of  asylums,  mere  spectators  of 
every  form  of  distressing  coercion,  without  a  word  of  sym- 
pathy, or  any  order  for  its  mitigation.  But  men's  hearts 
had  on  this  subject  become  gradually  hardened.  In  medical 
works  of  authority,  the  first  principle  in  the  treatment  of 
lunatics  was  laid  down  to  be  fear,  and  the  best  means  of 
producing  fear  was  said  to  be  punishment,  and  the  best 
mode  of  punishment  was  defined  to  be  stripes.  The  great 
authority  of  Dr.  Cullen,  certainly  one  of  the  most  enlight- 
ened physicians  of  his  time,  was  given  to  this  practice,  al- 
though his  theory  of  madness  was,  that  it  depended  upon 
an  increased  excitement  of  the  brain. 


*  Browne :  What  Asylums  were,  are,  and  ought  to  be.     Edinburgh, 
t  We  have  seen  that  examples  like  those  referred  to  have  not  entirely  been  un« 
known  in  the  present  century. 


IN    V/OMEN.  l6l 

"Thus,  by  degrees,  restraints  became  more  and  more  se- 
vere, and  torture  more  and  more  ingenious.  Among  manj 
cruel  devices,  an  unsuspecting  patient  was  sometimes  in- 
duced to  walk  across  a  treacherous  floor;  it  gave  way,  and 
the  patient  fell  into  a  bath  of  surprise,  and  was  there  half 
drowned  and  half  frightened  to  death.* 

"  In  some  continental  asylums  the  patients  were  chained 
in  a  well,  and  the  water  was  allowed  gradually  to  ascend,  in 
order  to  terrify  the  patient  with  the  prospect  of  inevitable 
death.  Other  methods  adopted,  even  within  the  last  sixty 
years,  for  controlling  the  phenomena  of  insanity,  can  only 
be  regarded  as  tacit  acknowledgments  of  the  general  ineffi- 
ciency of  medicine,  and  of  the  coarse  determination  of  vain 
or  ignorant  men  to  effect  by  force  what  they  could  not  ac- 
complish by  science.  We  read  with  almost  as  much  amuse- 
ment as  wonder  the  respectful  acknowledgment  of  Dr. 
Hallaran,  that  Dr.  Cox  made  known  to  the  profession  the 
'  safe  and  effectual  remedy  '  of  the  circulating  swing,  the  in- 
vention of  which  Dr.  Cox  '  generously  gives  the  credit  of 
to  Dr.  Darwin;  this  invention  being  one  by  means  of  which 
the  maniacal  or  melancholic  patient,  fast  bound  on  a  sort 
of  couch,  or  in  a  chair,  was  rotated  at  various  rates  up  to 
one  hundred  gyrations  in  a  minute.  This  machine  was  used 
with  two  indications;  the  horizontal  position  being  adopted 
when  the  object  was  to  procure  sleep ;  and  the  erect  posture, 
the  other  failing,  in  cases  of  excitement,  to  procure  intesti- 
nal action.  It  is  acknowledged  that  patients  once  subjected 
to  the  swing  were  ever  afterwards  terrified  at  the  mention  of 
it;  that  it  lowered  the  pulse  and  the  temperature  to  such  a 
degree  as  to  alarm  the  physician ;  that  it  occasioned  a  '  dis- 
agreeable suffusion  of  the  countenance,'  frequently  leaving 
an  ecchymosis  of  the  eyes ;  that  it  acted  as  an  emetic,  and 
as  a  hypercathartic;  but  still  it  was  lauded  as  reducing  the 
unmanageable,  and,   stranger   still,  as  causing  the   melan- 

*  It  was  with  reference  to  this  bath  of  surprise,  which  was  said  t<i  have  effected 
actual  cures,  that  Esquirol  remarked,  justly  enough,  "  I  should  as  soon  think  of 
recommending  patients  to  be  precipitated  from  the  third  story  of  a  house,  be- 
cause some  lunatics  have  been  known  to  be  cured  by  a  fa.l  on  the  head." 

II 


l63  REFLEX   INSANITY 

choly  to  take  '  a  natural  interest  in  the  affairs  of  life.'  It  is 
curious  to  be  told,  also,  that  the  inconvenient  effects  men- 
tioned were  induced  more  certainly  when  the  patient  was  in 
the  erect  position.  Worse  consequences  occasionally  re- 
sulted, I  believe,  from  this  barbarous  invention;  which 
probably  rendered  Dr.  Hallaran's  recommendation,  that  no 
'well-regulated  institution,  intended  for  the  reception  and 
relief  of  insane  persons,'  should  be  unprovided  with  a  ma- 
chine of  that  description,  ineffectual.  Allusion  is  made  to 
the  practice  in  Esquirol's  work,*  in  which  he  describes  '  la 
machine  de  Darwin  '  as  reseinbling  the  jeu  de  bague,  or 
treadmill,  and  he  speaks  of  it  as  having  passed  from  the 
arts  into  medicine.  It  found  some  temporary  favor  on  the 
continent;  but  the  violent  evacuations  produced  by  its  em- 
ployment, followed  by  fainting  and  excessive  debility,  led  to 
its  disuse.  Dr.  Cox  had  advised  its  being  used  in  some 
'hopeless'  cases,  in  the  dark,  with  the  addition  of  unusual 
noises,  smells,  etc.,  that  every  sense  might  be  assailed;  but 
I  do  not  think  that  this  advice  was  ever  acted  upon."  f 

In  the  women's  galleries  in  Bethlem,  the  same  au- 
thor tells  us,  they  found  in  one  of  the  side  rooms 
"  about  ten  patients,  each  chained  by  one  arm  or  leg 
to  the  wall ;  the  chain  allowing  them  merely  to  stand 
up  by  the  bench  or  form  fixed  to  the  wall,  or  to  sit 
down  on  it."  For  a  dress,  each  had  only  a  sort  of  a 
blanket-gown,  made  like  a  dressing-gown,  but  with 
nothing  to  fasten  it  round  the  body.  The  feet  were 
without  shoes  or  stockings.  Some  of  these  patients 
were  lost  in  imbecility,  dirty,  and  offensive  ;  associa- 
ted with  them  were  others  capable  of  coherent  con- 
versation, and  sensible,  and  accomplished.  Many 
women  were  locked  up  in  their  cells,  chained,  with- 

•  Conolly,  pp.  12-15.  t  Loc.  cit.,  vol.  i.  p.  156. 


IN  WOMEN.  163 

out  clothing,  and  with  only  one  blanket  for  a  cov- 
ering.* 

"  At  that  time,  when  a  young  and  accomplished  woman, 
for  example,  affected  with  acute  mania,  violent,  noisy,  mis- 
chievous, regardless  of  cleanliness,  arrived  at  a  large  asy- 
lum, she  was  forcibly  undressed,  fastened  down  on  loose 
straw,  had  strong  medicine  forced  down  her  throat,  and  was 
then  left  and  neglected  for  many  hours.  The  straw  tortured 
her  from  head  to  foot,  but  she  could  not  move  her  hands. 
Her  position  galled  and  fretted  her;  but  her  feet  were  fas- 
tened, and  she  could  not  change  it.  Sickness  and  purging 
were  produced  by  the  medicine ;  and  she  was  permitted  to 
lie  for  twelve  hours  in  a  state  of  indescribable  distress,  then 
taken  up,  laid  on  the  stone  pavement,  mopped  or  broomed, 
and,  last  of  all,  when  quite  subdued  and  half  dead,  had, 
perhaps,  a  bath  and  some  few  decent  attentions."  f 

And  again :  — 

"The  history  of  each  patient,  and  the  afflictions  which 
had  caused  their  minds  to  give  way,  would  now  receive  at- 
tention in  all  good  asylums.  But  the  day  had  not  arrived 
for  such  kind  sympathies,  and  on  arriving  at  the  large  and 
crowded  house  the  patient  was  undressed,  with  small  show 
of  gentleness,  by  several  young  women,  and  placed  at  once 
in  a  crib,  on  straw,  and  fastened  to  it  by  the  feet,  her  hands 
being  confined  by  iron  hand-locks,  and  a  tight  waistcoat  put 
around  the  trunk  of  the  body  and  round  her  arms,  the  offices 
of  the  nurses  concluding  for  the  time  with  the  administra- 
tion of  a  dose  of  purgative  salts.  When  the  patient,  not  yet 
forgetful  of  the  decencies  of  life,  asked  what  she  was  to  do 
if  she  wanted  to  get  out  of  bed,  the  nurses,  hardened  by 
their  vocation,  merely  answered  her  in  the  most  vulgar  terms. 
Having,  in  this  miserable  restraint,  become  dirty,  which 
was  inevitable,  the  patient  was  taken  out  of  bed,  carried  to 
the  pump,  and  pumped  upon  with  cold  water,  and  then,  un« 

•  Loc.  cit.,  p.  26.  t  Ibid.,  p.  48. 


164  REFLEX    INSANITY 

dried,  taken  back  to  her  crib,  and  fastened  down  again,  but 
on  fresh  straw  ;  an  attention  not  then  in  all  cases  considered 
necessary.  All  her  remonstrances  to  the  women  about  her 
were  laughed  at.  Long  afterwards  she  still  remembered  her 
own  expressions  and  theirs,  her  appeals  to  them  as  women, 
her  prayers  for  pity,  and  their  too  ready  reply,  which  shut 
out  hope  —  'You  don't  know  what  a  mad-house  is  yet,  but 
we  will  teach  you.'  In  the  same  room  there  were,  she  re- 
membered, several  maniacs,  all  in  chains  or  restraints  of 
some  kind,  singing,  swearing,  beating  the  walls.  This 
scene,  and  her  aggravated  wretchedness,  made  her  worse; 
and  as  she  could  not  get  up  and  move  about,  she  could  only 
sing  or  shout  aloud  like  the  rest.  For  six  weeks  siie  was 
kept  in  that  place  of  torment,  and  in  those  restraints;  and, 
like  most  of  the  patients  of  those  old  asylums,  the  story  of 
her  restraints  was  written  in  broad  indelible  scars  on  her 
wrists,  but  in  still  worse  characters  on  her  memory."  * 

That  such  abuses,  thus  related  by  a  superintendent 
himself,  were  more  common  with  women  than  with 
men,  there  can  be  no  question.  It  is  still  so,  to  the 
degree,  more  or  less  marked  as  this  may  be,  to  which 
they  still  exist.  And  there  are  reasons  why  it  might 
be  expected  that  such  should  be  the  case,  as  is  im- 
plied by  the  author  from  whom  we  have  been  quoting. 

Dr.  Conolly  says,  — 

"  On  the  female  side  of  the  house,  where  the  greatest 
daily  amount  of  excitement  and  refractoriness  was  to  be 
met  and  managed,  the  cases  of  recent  insanity  in  young 
women,  and  especially  the  cases  of  puerperal  insanity,  and 
those  arising  from  lactation,  were,  perhaps,  the  first  to  at- 
tract particular  notice  in  reference  to  the  new  system.  Any- 
where but  where  restraints  are  indiscriminately  employed, 
such  cases  would   seem  the   likeliest  to  be  regarded  with 

•  Loc.  cit.,  p.  124. 


IN    WOMEN.  165 

interest  and  compassion,  and  to  be  treated  with  gentleness. 
But  as  thej  are  usually  attended  with  a  great  degree  of  ex- 
citement, and  with  a  lively  propensity  to  every  kind  of  mis- 
chief, and  consequently  occasion  much  trouble,  these  cases 
had  become  more  especially  and  constantly  subjected  to 
severe  coercion.* 

"  The  subjects  of  this  coercion  were,  some  of  them,  wo- 
men of  middle  age,  who  had  been  handsome,  and  who  pos- 
sessed considerable  acuteness  of  intellect,  ingenuity,  and 
activity,  but  whose  lives  had  been  a  sort  of  troubled  ro- 
mance ;  profligate,  intemperate,  violent,  regardless  of  do- 
mestic ties,  their  children  abandoned  to  all  the  evils  of  home- 
less poverty,  themselves  by  degrees  given  up  to  utter  reck- 
lessness, they  had  been  the  cause  of  ruin  and  shame  to  their 
families,  and  the  history  of  their  wild  life  had  closed  with 
madness.  Others,  and  not  a  few,  were  the  victims  of  the 
vices  of  those  of  a  station  superior  to  them,  and  left  al 
length  to  struggle  with  difficulties,  and  mortifications,  an-d 
remorse,  beneath  which  reason  gave  way.  In  these  patients 
all  violent  methods  produced  greater  obstinac}',  greater  de- 
termination to  give  trouble,  to  do  mischief,  and  to  commit 
all  kinds  of  outrages. f 

"Delicate  young  women,  affected  with  mania,  were  tied 
to  the  bed,  or  half-smothered  by  servant-women  and  men, 
or  fastened  down  by  sheets  twisted  into  the  shape  of  cables, 
and  tightly  bound  round  the  body  and  round  the  bed.  In 
this  miserable  condition  cleanliness  is  neglected,  and  the 
patient  suffers  from  heat  and  thirst,  and  becomes  exhausted 
by  vain  struggles.  The  patient  becomes  rapidly  emaciated 
and  perfectly  frantic.  Nothing  can  allay  the  irritation  cre- 
ated by  the  useless  crowd,  by  the  disorder  of  the  room,  and 
the  closeness  of  the  atmosphere,  and  all  the  horrors  which 
in  the  course  of  a  few  dreadful  days  have  been  needlessly 
accumulated  about  the  chamber  of  a  patient  laboring  under 
an  excited  brain,  and  whose  malady  all  these  things  do  but 
increase.    But  in  these  unhappy  cases  the  friends  still  often 

•  Loc.  cit,  p.  107.  t  Ibid,  p.  127, 


l66  REFLEX   INSANITY 

oppose  measures  of  a  difterent  kind,  preferring  the  absolute 
secrecy  thrown  over  the  malady  before  all  sensible  consid- 
erations. Their  prejudices  and  weakness  find  support  in 
the  arguments  or  insinuations  of  the  attendants,  who  are 
glad  to  be  relieved  from  trouble,  and  who  commonly  neglect 
to  provide  against  any  danger,  except  by  debarring  the  pa- 
tient from  muscular  movement  as  much  as  possible,  and  as 
long  as  possible.  If,  happily,  such  cases  are  transferred  to 
the  care  of  attendants  who  have  been  taught  not  to  rely 
upon,  or  even  to  have  recourse  to,  restraints,  the  alteration 
effected  in  a  day  or  two  is  such  as  to  make  it  difficult  to  be- 
lieve that  the  patient  is  the  same  person  seen  before.  If  the 
patient  is  removed  from  home  to  a  tranquil  asylum,  the 
change  is  greater  still.  At  home  the  patient  is,  perhaps, 
the  cause  of  indescribable  confusion  :  all  domestic  regularity 
is  interrupted,  the  servants  speak  in  whispers,  the  neighbors 
avoid  the  house.  Days  and  nights  are  passed  in  anxiety  or 
terror.  But  the  patient  who  has  unconsciously  caused  all 
this  disturbance  becomes,  when  taken  to  an  asylum  con- 
ducted on  good  principles,  quite  an  altered  person ;  disturb- 
ing nobody,  and  behaving  peaceably,  and  even  seeming 
happy  among  new  associates,  and  in  scenes  unconnected 
with  the  real  or  imaginary  griefs  of  the  home  so  lately 
quitted.  Such  sudden  improvement  certainly  almost  ex- 
ceeds belief;  but  the  instances  of  it  are  not  even  rare.  Ev- 
ery physician  conversant  with  practice  in  cases  of  insanity, 
must  have  witnessed  these  almost  marvellous  metamor- 
phoses many  times."  * 

Let  it  not  be  supposed  that  the  fearful  pictures  I 
have  now  shown  of  the  attention  paid  the  most  sa- 
cred of  human  temples  by  medical  men  are  either 
overdrawn  or  from  a  wholly  by-gone  age.  They 
merely  represent  what  I  have  myself  witnessed  upon 
more  than  one  occasion  here  in  Massachusetts  w^ithin 

•  Loc  cit,  p.  329. 


IN    WOMEN.  167 

the  past  few  years.  Such  cases,  resulting  irom  the 
neglect  or  omission  of  the  profession  to  prevent  their 
occurrence,  become  in  reality  acts  of  commission 
upon  its  part.  I  make  no  reflection  upon  the  man- 
agement of  asylums,  for  it  is  well  known  that  gross 
abuses  of  the  kind  described  are  no  longer  permitted 
to  occur  therein  ;  but  there  are  hundreds  of  insane 
women  in  each  of  our '  States,  some  of  whom  have 
already  been  in  hospitals,  others  of  whom  have  never 
received  even  the  partial  and  necessarily  imperfect 
examination  it  is  there  customary  to  make,  who  are 
now  under  treatment  outside  these  hospitals,  or  rather 
under  no  medical  treatment  whatever,  but  subject 
only  to  the  brutalities  of  the  town's  officials  who 
have  them  in  charge.  For  further  evidence  upon  this 
subject,  I  need  merely  refer  to  the  report  of  the  Com- 
mission of  which  I  was  then  a  member.*  If  such 
outrages  still  exist  in  Massachusetts,  there  is  reason 
to  believe  they  are  not  wholly  unknown  in  other 
States  of  the  Union,t  and  it  is  the  duty  of  the  profes- 
sion to  look  to  it  that  they  are  at  once  made  to  cease. 
I  would  not,  however,  while  allowing  the  preven- 
tion at  hospitals  of  the  open  abuse  of  female  patients, 
be  understood  to  admit  that  all  is  there  accomplished 


*  Renort  of  the  Commissioners  (Quincy,  Hitchcock,  and  H.  R.  Storer)  on 
Insanity  to  the  Legislature  of  Massachusetts.     Pub.  Doc.  1864,  Senate,  No.  72. 

t  The  facts  in  the  case  are  but  too  patent.  They  were  acknowledged  to  exist 
in  two  other  States  at  the  moment  the  above  was  written  (American  Journal  of 
Insanity,  Jan.,  1865).     They  undoubtedly  exist  in  everv  State  of  the  Union. 


l68  REFLEX    INSANITY 

that  might  and  ought  to  be  done.  Far  from  this. 
Neglect,  systematic  and  customary  though  it  may  be, 
of  any  means  or  measure  that  may  tend  to  the  cure 
of  a  patient,  or  a  class  of  patients,  is  in  reality  almost 
as  grievous  a  wrong  as  a  harm  intentionally  inflicted. 
Between  omission  and  commission  there  is  at  times 
but  very  little  difference  as  regards  the  injury  that  is 
done. 

Let  me  here  quote,  as  pertinent  to  this  question, 
from  a  late  report  of  the  State  Hospital  for  the  Insane 
of  California  —  a  report  characterized  by  Dr.  Earle, 
of  the  Northampton  Asylum,  as  "  essentially  different 
in  character  from  any  other  from  the  California  hos- 
pital which  has  come  under  our  observation,  its  par- 
ticular object  appearing  to  be  an  exposition  of  the 
defects  of  the  hospital  as  a  curative  establishment."  * 

"  Its  beautiful  edifice,"  says  Dr.  Tilden,  the  super- 
intendent, "  its  well-cultivated  yards  and  gardens,  its 
wholesome  food,  its  comfortable  clothing,  its  scrupu- 
lously clean  halls,  rooms,  beds,  and  bedding,  its  ex- 
cellent police  regulations,  combine  in  making  a  prison 
of  the  first  class ;  and,  if  such  was  the  original  pur- 
pose, I  see  not  how  it  could  have  been  more  admira- 
bly accomplished.  If,  however,  in  creating  a  charity 
so  munificent,  so  noble,  it  was  intended  to  establish 
an  asylum,  with  hospital  appliances,  for  the  cure^  as 
well  as  the  care  and  safe-keeping  of  the  insane,  I  am 

*  American  Journal  of  the  Medical  Sdences,  April,  1865,  p.  445 


IN   WOMEN.  169 

free  to  say  it  is,  in  my  opinion,  a  most  signal  failure.' 
And  again,  he  says,  "  If  there  is  any  marked  differ- 
ence between  it  and  a  well-conducted  State  prison,  it 
is  in  favor  of  the  latter,  from  the  fact  that  means  of 
employment  are  provided  for  its  inmates,  while  the 
inmates  of  the  asylum  spend  their  days  in  idleness." 
And  again,  "  It  will  hardly  be  contended,  I  think, 
that  our  newspapers  and  a  little  gymnasium,  with  a 
solitary  swing  in  the  female  department,  can  give  the 
asylum  of  California  a  claim  to  the  character  of  a 
curative  institution." 

"  The  general  use  of  mechanical  restraint,"  says  Dr. 
Tuke,  "  arose  from  the  idea  impressed  upon  the  keep- 
ers of  asylums,  no  less  by  the  highest  authorities  than 
by  a  venerable  antiquity,  that  it  was  the  necessary  and 
best  mode  of  treatment.  It  was  connected,"  he  con- 
tinues, ''•  with  a  theoretical  ignorance  of  the  nature 
and  pathology  of  insanity."  *  The  same  should  be 
said  of  tlie  neglect  to  extend  to  an  insane  woman  the 
same  method  of  examination  and  of  treatment  which 
would  be  considered  imperative  for  the  same  woman 
laboring  under  any  other  possibly  reflex  form  of 
disease. 

I  have  quoted  upon  this  point  the  pithy  corollary 
of  Dr.  Azam,  that  for  organic  causative  disease,  phys- 
ical means  only  are  effectual ;  and  I  have  given  the 
corroborative  testimony  of  Dr.  Tuke,  regarding  the 

*  Manual  of  Psychological  Medicine,  p.  76. 


lyo  REFLEX    INSANITY 

chronic  and  supposed  incurable  cases  of  insanity  in 
women  now  at  the  Morningside  Asylum.  Let  me 
submit  a  word  or  two  in  addition  from  still  other 
superintendents.     We  are  told  that,  — 

"With  regard  to  the  detection  of  internal  disease,  great 
care  is  required,  as  many  of  those  symptoms  on  which  the 
practitioner  generally  relies  as  aids  to  diagnosis  are  wholly 
suppressed.  Insane  persons  frequently  evince  either  great 
insensibility  to,  or  power  of  enduring  pain,  and  hence  the 
light  afforded  by  painful  and  morbid  sensations  is  absent 
in  the  internal  and  constitutional  diseases  affecting  per- 
sons of  unsound  mind.  From  this  cause,  examinations 
after  death  occasionally  reveal  organic  lesions  and  changes 
which  had  not  previously  been  supposed  to  exist,  and  it  re- 
quires careful  attention  to  the  physical'signs  present,  and  a 
close  observation  of  disordered  functions  and  constitutional 
peculiarities,  in  order  to  discover  the  disease  which  is,  per- 
haps, secretly  undermining  the  vital  powers.* 

"  In  the  purely  medical  aspects  of  the  subject,"  it  has  been 
remarked  by  the  same  author,  "  there  appears  in  some  quar- 
ters an  indolent  and  ultra-expectant  mode  of  regarding 
mental  diseases,  which,  if  pursued  to  its  legitimate  conse- 
quences, must  end  in  the  utter  repudiation  of  medical  sci- 
ence and  skill  in  their  treatment.  For  in  the  reports  of 
some  large  asylums,  I  observe  that  medical  treatment  is  in- 
timated to  be  of  little  avail,  one  or  two  drugs  being  men- 
tioned as  the  only  medicinal  agencies  employed.  If  this  be 
the  correct  principle,  if  medical  science  can  afford  no  greater 
aid  in  the  cure  of  insanity,  it  is  surely  incumbent  on  the 
medical  officers  who  entertain  these  views  at  once  to  resign 
their  appointments  as  such,  and  henceforth  leave  the  care 
of  the  insane  to  persons  of  ordinary  education.  For  my 
own  part  I  entertain  a  very  different  opinion.  I  believe  that 
even  in  this  apparently  unpromising  department  of  medi- 
cine great  results  may  be  achieved ;  and  that  by  a  more 

*  Kobinson:  Prevention  and  Treatment  of  Mental  Disorders,  p.  tSj. 


IN   WOMEN.  171 

perfect  acquaintance  with  the  laws  regulating  the  phenom- 
ena of  the  healthy  mind,  by  a  more  extended  knowledge  of 
the  properties  of  the  innumerable  substances,  natural  and 
artificial,  which  are  capable  of  acting  upon  the  nervous 
structures,  and  through  them  upon  the  mental  phenomena, 
and  by  a  more  careful  investigation  of  the  circumstances 
influencing  the  production  of  morbid  changes  in  the  ner- 
vous system,  a  merely  disordered  and  structurally  uninjured 
brain  may  be  rendered  as  amenable  to  curative  agencies  as  a 
disordered  liver  or  kidney."  * 

Bucknill  says, — 

"  The  medicinal  treatment,  therefore,  must  be  founded, 
not  upon  the  general  resemblance  of  symptoms  in  different 
cases, t  but  upon  their  points  of  dissemblance,  and  upon  the 
discrimination  of  ultimate  diagnosis;  not  the  primary  diag- 
nosis which  recognizes  a  case  of  insanity,  but  upon  the  ulti- 
mate diagnosis  which,  as  nearly  as  possible,  refers  the  symp- 
toms of  each  individual  case  to  the  exact  pathological  con- 
dition from  which  they  arise."  J 

Esquirol  exclaims,  — 

"  What  misfortunes  and  obstacles  must  those  practitioners 
have  encountered  who  have  been  only  able  to  see  one  indi- 
vidual disease  in  all  the  insanities  which  they  have  nad  to 
treat!  They  were  not  ignorant  that,  delirium  being  symp- 
tomatic of  almost  all  diseases  when  approaching  a  fatal 
termination,  insanity  might  be  also  entirely  symptomatic; 
they  were  not  ignorant  that  there  are  instances  of  insanity 
evidently  sympathetic;  they  knew  that  a  thousand  exciting 
and  predisposing  causes  give  rise  to  insanity;  but  paying  no 
attention  except  to  the  most  obvious  symptoms,  they  have 
permitted  themselves  to  be  imposed  upon  by  the  impetuos- 
ity, the  violence,  the  mobility  of  these;  they  have  neglected 
the  study  of  the  causes  of  insanity,  and  that  of  the  relation 
of  the  causes  with  the  symptoms.     Under  the  domination 

*  Robinson :  Prevention  and  Treatment  of  Mental  Disorders,  p.  225. 
t  It  will  be  noticed  wliat  a  blow  is  this  remajk  to  the  usual  syFteni  of  classifi' 
cation  of  the  insane.  t  Loc.  cit..  p  45j- 


172  REFLEX    INSANITY 

of  theories,  some  have  only  been  able  to  see  the  existence 
of  inflammation,  have  accused  the  blood,  and  abused  the 
lancet;  others,  believing  in  irritating  bile,  have  checked  the 
secreting  organs,  and  injured  their  functions.  They  have 
been  prodigal  of  emetics  and  drastics.  Some,  having  only 
taken  into  account  the  nervous  influence,  have  given  anti- 
spasmodics in  excess.  All  have  forgotten  that  the  practi- 
tioner ought  to  have  present  to  his  mind  grand  general 
views  —  the  systematic  ideas  which  dominate,  which  consti- 
tute medical  science,  the  art  which  ought  especially  to  de- 
vote itself  to  a  thorough  knowledge  of  the  circumstances, 
and  of  the  symptoms,  which  are  capable  of  disclosing  the 
causes,  the  seat,  and  the  nature  of  the  malady  which  it  has 
to  combat.  Often  one  must  vary,  combine,  modify  the 
means  of  treatment;  for  there  is  no  specific  treatment  of 
insanity.  As  this  malady  is  not  identical  in  all  persons,  so 
it  has  in  every  individual  its  different  causes  and  characters; 
so  new  combinations  are  required,  and  a  new  problem  is  to 
be  solved  for  each  insane  person  under  treatment."* 

What  grand  general  views,  let  me  ask,  what  sys- 
tematic ideas,  what  search  for  different  causes  and 
characters,  and  for  new  combinations,  the  resort  to 
what  means  of  solving  the  problem,  do  we  find  in 
the  usual  and  most  ancient  method  of  treating  insane 
women  ?  That  I  am  neither  doing  injustice  by  this 
question,  nor  venturing  an  opinion  without  a  sufficient 
reason,  I  may  be  permitted  to  refer  the  profession  to 
extended  papers  by  leading  authorities  upon  the  sub- 
ject, who  may  be  supposed  to  have  given  a  fair  state- 
ment of  the  present  methods  of  medically  treating 
the  insane.  As  instances  in  point,  I  will  name  Dr. 
Forbes  Winslow's  articles  on  the  Treatment  of  In- 

*  Maladies  Mentales. 


IN   WOMEN.  173 

sanity,  Ancient  and  Modern,*  and  on  the  Medical 
Treatment  of  Insanity  ;  f  those  by  Schroeder  van  der 
Kolk,  X  even  the  excellent  one  to  which  I  have  already 
referred  in  another  part  of  this  report,  and  that  by 
Dr.  Ranney,  Physician  to  the  City  Lunatic  Asylum 
of  New  York,§  which  enjoyed  the  honor  of  being  re- 
produced, with  the  full  discussion  to  which  it  gave 
rise  at  the  meeting  of  American  Superintendents,  to 
whom  it  was  first  communicated,  in  one  of  the  Eng- 
lish psychological  journals.  ||  In  none  of  them  do  we 
find  recognition  of  the  claims  of  a  decided  and  spe- 
cial treatment  for  insane  women,  although,  in  the 
case  of  Winslow,  it  will  be  recollected  that  he  had 
acknowledged  the  special  causation  of  much  of  their 
mental  disturbance,  as  suggested  by  Laycock. 

I  would  not  deny  the  occurrence  in  psychological 
literature  of  sentences  like  the  following,  for  I  have 
already  quoted  many  of  them ;  but  they  have  as  yet 
fallen  without  fruit,  and  dead.  "  Sex,"  says  Dr.  Rob- 
ertson, "  is  doubtless  an  indication  of  treatment  in  the 
many  cases  connected  with  uterine  disease."  ^ 

Dr.  Conolly,  as  usual,  here  speaks  sensibly  and  in- 
telligibly. 

*  Journal  of  Psychological  Medicine,  Jan.,  1850. 
t  Ibid,  April,  1854. 

t  British  and  Foreign  Medico-Chirurgical  Review ;  American  Journal  of  In* 
sanity,  July,  i860. 
§  Ibid,-  July,  1857. 

II  Asylum  Journal  of  Mental  Science,  April,  1858,  p.  450. 
H  Ibid.,  Jan.,  1859,  p.  277. 


174  REFLEX   INSANITY 

"  The  physician's  office  is  assuming  in  these  times  a  higher 
character  in  proportion  as  he  ceases  to  be  a  mere  prescnber 
of  medicines,  and  acts  as  the  guardian  or  conservator  of 
public  and  of  private  health;  studious  of  all  agencies  that 
influence  the  body  and  the  mind,  and  which,  affecting  in- 
dividual comfort  and  longevity,  act  widely  on  societies  of 
human  beings.  Changes  are  gradually  taking  place  even 
in  special  walks  of  medical  practice,  in  conformity  to  the 
enlightened  principles  by  which  the  exertions  of  the  officers 
of  general  health  are  directed;  and  these  principles  find  an 
application,  and  are  strikingly  illustrated,  in  the  modern 
asylums  and  modern  treatment  of  the  insane.  Obscurity 
may  yet  hang  over  the  origin  of  mental  derangement;  the 
explanation  of  sudden  recoveries  may  continue  difficult;  the 
alterations  incidental  to  portions  of  nervous  matter  may 
baffle  investigation,  and  the  possible  varieties  in  the  con- 
dition of  the  blood,  often  apparently  associated  with  mental 
disturbance,  may  be  yet  unknown,  or  incapable  of  satisfac- 
tory elucidation;  but  general  means  have  been  revealed  to 
men  of  science,  conducing  to  important  modifications  and 
ameliorations  of  mental  malady."* 

It  is  possible  that  I  may  be  able  to  afford  some  light 
as  to  the  frequency  with  which  these  means  are  at 
present  resorted  to  in  the  case  of  insane  women.  I 
have  spoken  of  the  neglect  of  special  measures,  as  in 
reality  the  prevalent  treatment  of  insane  women.  Of 
such  a  method  as  is  the  present,  Dr.  Bucknill  speaks 
as  follows :  — 

"Although  specific  drugs  are  out  of  vogue,  narrow  and 
stereotyped  modes  of  treatment  are  scarcely  less  dangerous; 
and  in  no  class  of  disease  does  the  treatment  need  to  be 
more  infinitely  varied  than  in  insanity.  In  other  wide 
classes,  some  broad  rules  may  be  laid  down  for  the  treat* 

•  Treatment  of  the  Insane,  p.  79. 


IN   WOMEN.  175 

ment;  and  although  physicians  may  differ  respecting  these 
rules,  they  will  be  found  to  adhere  to  one  or  other  set  of 
opinions  respecting  them.  Thus,  one  feeds  in  fevers,  another 
depletes;  but  in  insanity,  cases  which  present  symptoms, 
at  first  sight,  of  close  resemblance,  demand  most  opposite 
modes  of  treatment;  and  cases  which  at  first  present  symp- 
toms most  unlike,  sometimes  require  to  be  treated  in  the 
same  manner.  An  educated  and  exact  observation  is  re- 
quired to  distinguish  between  the  acute  delirium  which 
arises  from  cerebral  hyperaemia  and  that  which  arises  from 
cerebral  excitement  in  sympathy  with  intense  irritation  of 
some  part  of  the  periphery  of  the  nervous  system ;  or  from 
the  cerebral  excitement  which  is  but  an  expression  of  the 
defective  nutrition  of  the  organ  from  poverty  of  the  blood; 
or  cerebral  excitement  propagated  to  all  parts  of  the  organ 
from  some  focus  of  irritation,  some  Joyer  of  disease  in  itself, 
as  a  small  portion  of  inflamed  substance  or  membrane,  or 
the  structural  mischiefs  surrounding  an  apoplectic  clot.  In 
all  these  instances  the  symptoms  may  bear  a  strong  resem- 
blance to  each  other,  and  yet  how  different  is  the  mode  of 
treatment  demanded  in  each  of  them."* 

It  has  been  asserted,  that  in  claiming  for  insane 
women  the  same  general  principles  of  treatment  by 
which  we  would  conduct  disease  to  a  successful  issue 
where  the  mind  is  unimpaired,  I  am  myself  endeavor- 
ing to  substitute  for  the  present  general  neglect  a 
narrow  and  stereotyped  method  of  practice.  Every 
one  familiar  with  the  modern  treatment  of  the  dis- 
eases of  women,  will  detect  and  deny  this  wretched 
libel.  It  is  just  the  man  who  does  not  treat  symp- 
toms, but  searches  faithfully  and  persistently  for  their 
ultimate  cause,  who  is  the  true  general  practitioner — < 

*  Loc.  cit,  p.  452. 


176  REFLEX    INSANITY 

he,  alone,  who  can  avoid  the  charge  of  blind  groping 
and  routine. 

In  one  of  my  previous  communications  upon  in- 
sanity as  of  reflex  causation  in  v^omen,  the  statement 
was  made,  with  all  respect  for  the  ability  and  zeal  of 
those  more  especially  engaged  in  the  management  of 
the  insane,  that  little  has  as  yet  been  undertaken  or 
accomplished  at  our  public  hospitals  for  the  cure  of 
insane  women. 

"  Does  he  mean  to  say,"  asks  an  anonymous  critic, 
whom  I  have  noticed  only  because  he  claims  to  have 
been  both  Assistant  Physician  and  Superintendent  of 
a  New  England  Asylum,  and  to  represent  the  opinion 
of  a  large  circle  of  his  fraternity — "does  he  mean 
to  say  that  superintendents  have  not  discharged,  as 
cured,  as  many  women  as  men.'*  Where  are  the 
statistics?"* 

To  the  statistics  thus  called  for,  although  I  have 
already  in  this  communication  expressed  an  emphatic 
belief  as  to  their  real  value,  I  am  yet  not  unwilling  to 
refer. 

I  should  have  produced  them  ere  this,  had  I  not 
preferred  that  they  should  be  called  for  by  any  gentle- 
man who  might  venture  to  deny  the  justice  of  my 
conclusions.  Those  who  appeal  to  statistics,  cannot 
refuse  to  be  governed  by  their  evidence. 

I  proceed  to  draw  additional  proof  of  the  correct 

*  Boston  Medical  and  Surgical  Journal,  sth  January,  1865,  p  453 


IN    WOMEN.  177 

ness    of  my  views  concerning   the  management  of 
insane  women :  — 

A.  From  the  statistical  evidence  of  asykims,  and 

B.  From  the  direct  evidence  of  those  having  asy- 
lums in  charge.* 

A.  In  the  first  place,  I  would  say  that  any  remarks 
I  may  have  made  respecting  the  medical  management 
of  insane  women  at  asylums,  apply  not  merely  to  our 
own  American  hospitals,  but  to  those  of  other  coun- 
tries also  —  so  that  no  argument  in  disproof  can  be 
drawn  from  the  comparisons  I  shall  proceed  to  fur- 
nish, inasmuch  as  these,  being  based  upon  nearly 
identical  data,  can  only  afford  identical  results. 

Secondly,  I  have  no  doubt,  and  I  am  willing  to 
allow,  that  as  many,  or  nearly  as  many  women  as 
men  are  yearly  discharged  from  asylums.  Any  basis 
that  may  be  named,  the  number  of  admissions,  for 
instance,  may  be  taken  for  the  calculation.     Selecting 

*  A  portion  of  the  evidence  that  will  now  be  presented  was  read  before  the  Suf- 
folk District  Medical  Society  of  Boston  on  January  28,  1865.  It  was  communica- 
ted to  the  Medical  and  Surgical  Journal  of  that  city  as  Article  IV.  of  the  series  I 
had  already  initiated,  upon  the  causation  and  treatment  of  insanity  in  women ; 
the  subject  being  one  whose  discussion  many  of  the  most  distinguished  phy- 
sicians in  this  country  are  pleased  to  consider  of  the  very  highest  importance. 
On  the  15th  of  February  I  received  the  fo'lowing  note:  "The  editors  of  the 
Journal  came  to  the  conclusion,  after  the  publication  of  the  last  article  relating 
to  this  discussion,  that  enough  space  had  already  been  given  to  it,  and  that  they 
would  decline  any  further  communication  on  the  subject."  With  this  decision  I 
have  not  found  fault,  the  gentlemen  referred*  to  best  understanding  their  own 
affairs.  So  many  inquiries,  however,  concerning  my  enforced  silence  have  been 
made  of  me  by  their  subscribers  who  had  seen  my  former  papers,  and  by  the 
gentlemen  who  were  present  at  the  reading  of  that  herein  embodied,  that  I 
should  certainly  have  published  through  some  other  medium  the  facts  here  pre- 
sented, had  they  not  been  so  relevant  to  the  main  subject  of  the  present  report. 

12 


178  REFLEX    INSANITY 

at  random  from  a  pile  of  hospital  reports,  I  will  give 
the  results  of  the  statistics  of  the  Worcester  State 
Hospital  for  the  space  of  thirty  years,  from  1833-62. 
In  a  total  of  over  6cxx>  patients,  there  were  admitted 
3273  males  and  3390  females,  and  were  discharged 
2962  males,  or  88  per  cent,  of  the  admissions,  and  3078 
females,  or  89  per  cent,  of  the  admissions,  a  difference 
of  I  per  cent,  in  favor  of  the  women. 

If  we  add  the  years  1863  and  '64,  the  percentage  is 
but  slightly  changed.  In  a  total  of  over  7000  patients, 
we  now  have  as  admitted  3503  males  and  3601  fe- 
males, and  as  discharged  2910  males,  or  81  per  cent, 
of  the  admissions,  a  loss  of  7  per  cent.,  and  3005 
females,  or  81  per  cent,  of  the  admissions,  a  loss  of  8 
per  cent. ;  the  proportions  of  discharges  in  the  two 
sexes  being  rendered  exactly  identical  by  the  com- 
parative loss  of  I  per  cent,  by  the  women. 

Thirdly,  I  have  also  no  doubt,  and  am  willing  to 
admit,  that  as  many,  or  nearly  as  many  women  as 
men  are  discharged  from  our  hospitals  as  recovered. 
This,  it  will  be  noticed,  is,  however,  a  very  different 
thing  from  being  discharged  as  cured  ;  and  this  again 
is  by  no  means  identical  with  being  discharged  cured. 

If  my  views  as  to  the  psycho-pathology  of  women 
are  correct,  not  only  as  many  women  as  men  ought 
to  be  discharged  cured,  but  very  many  more.  This, 
however,  does  not  occur  in  practice. 

To  return  to  the  question  of  relative  recoveries.    At 


IN   WOMEN.  179 

the  Worcester  State  Hospital,  during  the  thirty  years 
first  mentioned,  and  upon  the  basis  of  admissions  then 
existing,  namely,  3273  males  and  3390  females,  there 
were  discharged  as  recovered,  1493  males,  or  44  per 
cent,  of  the  admissions,  and  1618  females,  or  45  per 
cent,  of  the  admissions ;  a  difference  of  i  per  cent,  in 
favor  of  the  females. 

Adding  again  the  years  1863  and  '64,  we  have  an 
admission  of  3503  males  and  3601  females,  and  a  dis- 
charge as  recovered,  of  1612  males,  or  45  per  cent, 
of  the  admissions,  a  gain  of  i  per  cent.,  and  1751 
females,  or  49  per  cent,  of  the  admissions,  a  gain  of 
4  per  cent. ;  showing  a  difference  of  4  per  cent,  in  the 
females,  and  a  comparative  gain  of  3  per  cent. 

At  the  Southern  Ohio  Lunatic  Asylum,  for  the 
nine  years  from  1855-64,  there  were  admitted  497 
males  and  499  females  ;  of  whom  were  discharged  as 
recovered,  261  males,  or  57  per  cent,  of  the  admissions, 
and  251  females,  or  50  per  cent,  of  the  admissions  ;  a 
proportion  of  7  per  cent,  in  favor  of  the  males. 

At  the  Taunton  State  Hospital,  for  the  nine  years 
from  1853-62,  there  were  admitted  1044  males  and 
1004  females,  and  were  discharged  as  recovered  404 
males,  or  38  per  cent,  of  the  admissions,  and  335 
females,  or  30  per  cent,  of  the  admissions ;  a  propor- 
tion of  8  per  cent,  in  favor  of  the  males. 

If  we  tabulate  the  results  of  these  three  hospitals, 
we  have  for  the  years  first  considered,  a  total  of  nearly 


l8o  REFLEX    INSANITY 

10,000  patients  admitted,  of  whom  4814  were  males, 
and  4933  were  females.  Of  the  former  there  were 
discharged  as  recovered  2158,  or  42  per  cent.,  and  of 
the  latter  2204,  or  44  per  cent. ;  a  difference  of  2  per 
cent,  in  favor  of  the  female. 

Adding  to  this  the  years  1863  and  '64  at  the 
Worcester  Asylum,  our  total  number  of  patients 
admitted  becomes  12,000;  6844  being  males,  and 
5104  females.  There  were  discharged  as  recovered 
2277  males,  or  31  per  cent.,  a  loss  of  11  per  cent., 
and  2337  females,  or  44  per  cent.,  the  proportion  here 
remaining  the  same.  The  difference  of  13  percent, 
which  had  been  relatively  gained  by  the  women,  and 
which  at  first  sight  might  have  seemed  an  absolute 
gain,  being  found  upon  comparison  to  be  exactly 
neutralized  by  the  loss  in  recoveries  of  the  men. 

The  statistics  that  have  now  been  given  were,  as  I 
have  said,  taken  at  random  from  many  reports  before 
me,  and  may  undoubtedly  be  considered  as  represent- 
ing the  truth,  such  as  it  is.  They  show,  it  will  be 
noticed,  an  apparent  variation  of  the  ratio  of  recoveries 
in  insane  women  at  the  different  hospitals  —  ranging 
from  50  per  cent,  at  Dayton  to  30  per  cent,  at  Taun- 
ton—  a  variation  to  be  explained  in  part,  by  the 
different  probable  character  and  nationality  of  the 
patients  at  the  two  hospitals ;  if  at  all  attributable  to 
difference  in  treatment,  it  may  partly  be  owing  to  the 
fact,  as  is  well  known,  that  Dr.  Gundry  has  paid  much 


IN   WOMEN.  l8l 

attention  to  insanity  as  caused  by  or  coincident  with 
the  puerperal  state.  These  variations,  however,  but 
tend  to  make  the  mean  that  I  have  presented  the 
more  reliable  in  reference  to  the  actual  percentage  of 
recoveries  of  insane  women  at  asylums. 

I  could  have  furnished  a  computation  upon  a  very 
much  larger  scale  had  it  been  necessary  ;  that  given 
is,  however,  sufficient  for  every  practical  purpose, 
more  especially  as  I  have  granted  all  that  could  by 
any  one  be  claimed  ;  namely,  that  at  our  hospitals  as 
many  insane  women  as  men  are  discharged  as  re- 
covered. 

It  will  not  be  uninteresting,  however,  to  compare 
these  results  with  what  obtains  abroad  ;  a  comparison 
that  so  far  as  I  am  aware  has  never  yet  been  made. 

At  the  York  Retreat,  in  England,  as  appears  from 
a  table  furnished  by  Tuke,  and  covering  a  period  of 
51  years,  from  1796  to  1857,  ^^®  average  proportion 
of  recoveries  as  compared  with  the  admissions  was 
49.54  per  cent,  of  males  and  49.50  per  cent,  of  fe- 
males, the  numbers  being  almost  exactly  identical.* 

It  was  Dr.  Thurnam's  opinion,  as  we  have  already 
seen,  that  the  proportion  of  recoveries  of  women  ex- 
ceeded those  of  men  by  about  20  per  cent. ;  indeed,  he 
is  said  to  have  estimated  this  excess  as  high  as  50  per 
cent.  A  most  surprising  differdnce  as  compared  with 
the  results  I  am  now  presenting. 

*  Psychological  Medicine,  p.  aoi. 


I  S3  REFLEX   INSANITY 

At  Bethlem,  during  ten  years,  53.8  per  cent,  of  the 
men  recovered,  and  54.4  per  cent,  of  the  women  ;  an 
excess  of  .6  per  cent,  in  favor  of  the  latter.* 

At  St.  Yon,  near  Rouen,  in  France,  the  difference 
in  favor  of  the  women  has  been  rated  at  3  per  cent,  f 

In  most  of  the  French  asylums  it  has  been  thought 
that  the  males,  discharged  as  recovered,  exceeded  the 
females  by  about  6  per  cent.  It  is  possible,  however, 
that  in  some  instances  these  computations  may  have 
been  made  by  comparison  with  the  total  number  of 
discharges,  as  was  the  case  in  the  English  statistical 
tables  presented  by  Farr.  The  excess  referred  to  has 
been  noticed  by  nearly  all  the  directors  of  asylums  in 
France,  and  has  been  explained  in  various  waj'S.  By 
some  it  is  regarded  as  due  to  "  a  humane  sentiment, 
which  induces  the  pliysicians  of  these  establishments 
to  shorten  as  much  as  possible  the  period  of  confine- 
ment for  the  men,  whose  labor  is  oftentimes  indispen- 
sable to  the  maintenance  of  their  families  ;  and,  on 
the  other  hand,  to  detain  the  females,  giving  them  the 
protection  of  the  asylum  as  long  as  possible,  in  view 
of  their  greater  helplessness,  and  of  the  dangers  to 
which  many  would  be  exposed  on  their  return  to  so- 
ciety ;  "  a  detention  which,  besides,  by  preventing  to  a 
certain  extent  their  marriage,  would  tend  to  check  the 


•  Hood :  Statistics  of  Bethlem  Hospital,  p.  73 ;  as  corrected  by  Tuke,  lot 
dt.,  p.  362. 

t  Parchap^e :  Notice  Statistique  sur  les  Ali^D^s  de  la  Seine  Inferieure,  p.  44 


IN    WOMEN.  1S3 

transmission  of  a  predisposition  to  the  disease  by  in- 
heritance. 

"  But,"  says  Legoyt,  "  ought  we  not  rather  to  at- 
tribute this  difference  to  the  greater  or  less  severity 
of  the  disease  itself,  depending  upon  the  difference  in 
causes  which  induce  insanity  in  the  two  sexes  ? "  * 

I  allow  the  validity  of  the  explanation  by  which 
the  apparent  disparity  is  done  away,  calling  attention 
only  to  the  admission  that  insanity  in  the  two  sexes 
may  be  owing  to  a  constantly  frequent  difference  in 
cause. 

Thus  far,  it  has  been  shown  that  the  discharges  of 
women  from  hospitals,  as  recovered,  is  about  equal  to 
that  of  men.  Let  it  not  be  supposed,  however,  that 
this  is  necessarily  a  proof  that,  ist,  these  recoveries 
are  always  cures ;  2d,  that  they  comprise  all  the 
women  who  might  be  cured ;  or,  3d,  that  they  are 
evidence  that  all  justifiable  resources  of  medical  treat- 
ment have  been  put  in  requisition. 

I  propose,  on  the  contrary,  by  pursuing  the  investi- 
gation a  little  further,  to  show  the  opposite. 

I.  Are  these  recoveries  always  cures?  It  is  a  deli- 
cate question  that  I  am  now  approaching ;  but  I  rely 
upon  the  good  nature  of  those  interested  in  the  matter 
who  are  my  personal  friends,  and  upon  the  fairness 
of  all  others,  that  they  take  no  offence  where  none  is 
intended. 

*  American  Journal  of  Insanity,  April,  i86i,p.  424. 


184  REFLEX    INSANITY 

In  view  of  the  coincidence  already  shown  to  exist, 
as  regards  the  relative  recoveries  of  the  two  sexes  in 
asylums,  at  home  and  abroad,  I  may  be  jDermitted  to 
seek  evidence  from  foreign  sources,  inasmuch  as  mi- 
nute data  have  not  yet  been  afforded  to  any  extent 
from  within  our  own  asylums.  An  identity  of  result 
may  of  course  be  supposed  to  have  been  occasioned 
by  similarity  of  cause. 

At  some  foreign  establishments,  nearly  one  third  of 
all  the  patients  treated  are  set  down  as  cures,  while  in 
others  only  three  or  four  per  cent,  of  the  recoveries 
are  claimed  as  the  result  of  treatment.*  As  this  state- 
ment is  given  from  Legoyt's  statistics,  by  his  transla- 
tor, the  well-known  physician  to  the  Long  Island 
Asylum  at  Sanford  Hall,  without  objection  or  other 
comment,  the  fact  is  probably  not  materially  different 
from  what  may  be  supposed  to  obtain  in  this  country 
also.f  No  exception  seems  to  have  been  taken  to  the 
statement  by  any  other  of  our  writers  on  insanity 
during  the  nearly  four  years  (1865)  since  these  statis- 
tics were  reproduced  by  Dr.  Barstow. 

The  difference,  to  which  I  have  referred,  is  sup- 
posed to  be  due  partly  to  accidental  circumstances, 
appearing  and  disappearing  at  different  asylums  at 
difierent  periods  of  time,  partly  to  the  diversity  of 
curative   measures  or  of  the  hygienic  conditions  by 

*  Deductions  from  the   Statistics  of  the   Establishments  for  the   Insane  it 
France,  for  the  twelve  years  from  1842  to  1853  inclusive, 
t  American  Journal  of  insanity,  April,  1861,  p.  433. 


IN   WOMEN.  185 

which  patients  are  surrounded,  and  partly  to  the 
longer  or  shorter  period  of  residence  at  the  asylum 
which  each  physician  may  order  as  requisite  for  his 
patient. 

"  This  may  be  done  on  the  part  of  the  physician  as  a  re- 
sult of  enlightened  experience  and  observation,  or  in  view 
sometimes  of  the  material  interests  of  the  institution  of 
which  he  has  the  charge.  We  may  suppose,  for  example, 
that  where  the  number  of  beds  is  found  inadequate  to  the 
wants  of  the  service,  and  where  maintenance  of  a  very  large 
number  of  patients  is  at  the  public  expense,  their  discharge 
is  more  easily  authorized  at  the  first  well-marked  symptoms 
of  returning  health,  than  where  such  maintenance  is  a 
source  of  income  to  the  establishment."  * 

It  is  allowed,  then,  by  alienists  of  acknowledged 
authority,  that  these  so-called  recoveries  are  not  aU 
ways  cures.  Are  they  generally  so.''  Before  enter- 
ing upon  this  question,  evidence  may  be  interesting 
as  to  what  has  been  supposed  the  curability  of  the 
insane,  positive  and  comparative,  as  to  sex. 

In  the  report  of  the  Massachusetts  Commissioners 
on  Lunacy  for  1854-55,  which  is  a  model  of  statis- 
tical research,  it  is  stated  that  there  were  of  insane 
men,  native  and  foreign,  in  Massachusetts,  1259  ;  and 
of  insane  women,  1373.  Of  the  men,  181  were  con- 
sidered curable,  and  1005  incurable  ;  leaving  73  un- 
accounted for.  Of  the  women,  225  were  considered 
curable,  and  999  incurable  ;  leaving  149  unaccounted 

•  American  Journal  of  Insanity,  April,  1861,  p.  423. 


l86  REFLEX   INSANITY 

for.*  Or,  in  other  words,  14  per  cent,  of  the  men 
were  considered  curable,  against  the  44  per  cent,  dis- 
charged as  recovered  from  the  Worcester  Hospital ; 
and  16  per  cent,  of  the  women,  against  45  per  cent. 
These  facts  are  the  more  interesting,  as  the  writer  of 
that  report  was  also  a  Trustee  of  the  State  Hospital  at 
Worcester,  whose  statistics  have  therefore  undoubted- 
ly passed  under  his  own  careful  scrutiny. 

It  may  be  urged  that  this  is  hardly  a  fair  basis  for 
comparisons,  as  Dr.  Jarvis's  estimates  were  of  the 
whole  insane  in  Massachusetts,  whether  at  hospitals 
or  at  home.  Fortunately,  he  has  provided  us  with 
other  and  more  pertinent  elements  of  computation. 
At  the  time  referred  to,  1854-55,  there  were  in  tlie 
Massachusetts  hospitals  for  the  insane,  522  men  and 
619  women.  Of  the  men,  85,  or  16  per  cent.,  were 
considered  curable;  and  of  the  women,  109,  or  17 
per  cent. ;  the  ratios  being  almost  identically  the 
same.f  Is  it  proper,  then,  to  compare  these  two 
classes  of  statistics  —  the  proportion  of  discharges  as 
recovered,  with  the  whole  number  of  admissions ; 
and  the  considered  curable,  with  the  whole  number 
at  the  hospitals?  In  view  of  their  apparently  con- 
stant character,  I  think  it  should  be  allowed.  It  may 
be  urged  that  the  number  of  incurable  insane  perma- 
nently resident  at  our  hospitals  invalidates  any  calcu- 

*  Report  on  Insanity  and  Idiocy  in  Massachusetts,  1855.     House  Doc  Na 
144,  p.  78. 
tibid. 


IN    WOMEN.  187 

lation  from  which  they  are  not  eliminated ;  but,  on 
the  other  hand,  it  may  be  judged,  from  the  constant 
character  of  the  statistics  I  have  already  given,  that 
this  number  is  also  constant ;  and,  besides,  who  has 
ever  given  us  a  standard  by  which  to  judge,  or  by 
which  he  has  judged,  of  the  incurability  of  insane 
women  ? 

From  the  evidence  given,  it  would  appear  that 
while  some  44  per  cent,  of  the  women  entering 
our  hospitals  are  annually  discharged  as  recovered, 
but  16  per  cent,  of  the  women  at  these  hospitals 
were  considered  by  the  competent  authority  whom  I 
have  quoted,  as  at  that  time  subjects  of  probable 
cure. 

It  is  possible,  however,  that  Dr.  Jarvis  intended  the 
word  curability  as  synonymous  with  capability  of 
recovery.  What  is  this  capability  of  recovery  of  in- 
sane women  ? 

In  women,  as  in  men,  it  has  been  seen  that  of  all 
admitted  to  asylums,  nearly  one  half  are  discharged 
well  or  much  improved.  A  very  marked  difference, 
however,  will  be  found  to  exist  between  the  sexes,  if 
we  compare  the  age,  not  of  the  patients,  but  of  their 
disease. 

At  the  French  asylums,  it  has  been  observed  that 
for  the  first  six  months  of  asylum  treatment,  the  re- 
coveries of  males  exceed  those  of  females,  while  for 


180  REFLEX   INSANITY 

the  next  six  months,  on  the  contrary,  the  proportion 
is  much  gieater  for  females  than  for  males.*  Dr. 
Tuke  has  given,  from  the  statistics  of  the  York  Re- 
treat, a  table  that  throws  much  light  upon  this  sub- 
ject. Like  one  of  those  that  I  have  already  present- 
ed, it  is  computed  from  a  period  of  sixty-one  years.f 

Proportion  of  Recoveries. 
Duration  of  disorder  when  admitted,  Men.        Women. 

First  attack,  and  within  three  months,     .     .  72.97  7323 

"  from  three  to  twelve  months,    .  43.07  44.20 

Not  first  attack,  and  within  twelve  months,  59-44  67  01 

First  or  not,  and  more  than  twelve  months,  13.29  22.59 

From  the  above,  it  appears  that  in  the  first  of  the 
classes  named,  the  excess  of  recoveries  in  women  was 
.26  per  cent.  ;  in  the  second  class,  1.13  per  cent.  ;  in 
the  third  class,  7'57  P^^  cent.  ;  and  in  the  fourtli  class, 
9.30  per  cent. 

From  sheets  of  the  First  Annual  Report  of  the 
Massachusetts  Board  of  State  Charities,  that  were 
kindly  afforded  me,  in  advance  of  publication,  by 
the  Secretary,  F.  B.  Sanborn,  Esq.,  I  was  enabled  to 
establish  a  computation  to  somewhat  the  same  effect, 
namely,  that  while  in  acute  and  sudden,  or  explcsive 
attacks  of  insanity,  the  percentages  of  recoveries  in 
the  sexes  are  at  present  nearly  identical,  in  chronic 
cases  there  is  quite  a  balance  in  favor  of  the  women. 
Thus,  at  the  Worcester  Hospital,  during  the  thirt};- 
two  years  of  its  existence,  there  have  been  — 

•  Legoyt,  loc  cit.,  p.  426.  t  Loc.  cit.,  p.  a6i. 


IN   WOMEN.  189 

Discharged  recovered.       Percentage  to  Admissions. 
Standing  of  Disease.  Males.  Females.  Males.        Females. 

I  year  or  less,   .     .     1242  1372  .55  .54 

I  to  2  years,  numbers  not  corresponding  with  each  other, 
as  reported.* 


2  to  5  years. 

112 

124 

.22 

.24 

5  to  10 

(( 

.   .     42 

53 

•15 

.20 

10  to  15 

(( 

12 

20 

.8 

•13 

15  to  20 

(( 

9 

9 

.13 

.21 

20  to  25 

(( 

7 

6 

.14 

.18 

Beyond  the  limit  last  named,  recoveries  practically 
cease.  It  appears,  then,  that  in  the  first  of  these  pe- 
riods the  proportions  of  recovery  between  the  two 
sexes  was  almost  identical ;  in  the  second  and  third, 
there  was  an  excess  of  2  per  cent,  in  favor  of  the 
women  ;  in  the  fourth,  of  5  per  cent.  ;  in  the  fifth, 
of  5  per  cent. ;  in  the  sixth,  of  8  per  cent. ;  and  in 
the  last,  of  4  per  cent. 

It  is  very  much  to  be  regretted  that  the  tables,  cal- 
culated in  the  Report  of  the  Board  of  State  Charities, 
which  I  have  just  quoted,  drawn  from  the  statistics  of 
the  Taunton  Hospital,  do  not  contain  a  statement  of 
the  relative  numbers  of  the  two  sexes  discharged  as 
recovered,  and  of  the  relative  numbers  of  admissions 
in  the  several  periods  stated,  as  I  should  thus  have 
been  able  to  have  compared  the  statistics  of  the  two 
hospitals  more  closely,  and  then,  by  combining  them, 

*  First  Annual  Report  of  the  Massachusetts  Board  of  State  Charities,  p.  io6. 
In  the  printed  tables  from  which  I  have  deduced  these  computations,  there  ia 
given  as  discharged,  recovered,  not  recovered,  or  dead,  of  the  class  referred  to 
above,  a  total  of  458  oatients,  male  and  female,  out  of  only  227  admissions. 


190  REFLEX   INSANITY 

have  procured  a  much  larger,  and  therefore  much 
more  reliable,  basis.* 

Again,  the  relative  mortality  of  the  two  sexes  at 
asylums  is  very  different,  or,  as  it  has  been  expressed 
by  the  director  of  an  asylum,  "  the  dangers  and  dis- 
comforts attending  a  residence  in  an  insane  asylum 
have  a  much  less  effect  upon  females  than  upon 
males."  Thus,  the  smallest  proportion  of  male 
deaths,  reported  at  the  French  hospitals,  during  the 
twelve  years  whose  statistics  we  have  examined,  was 
15  per  cent,  while  of  females  the  minimum  mortality 
was  but  12  per  cent.f 

The  average  mortality  during  the  whole  of  this  pe- 
riod was  in  males,  54  per  cent.,  and  in  females,  45 
per  cent. ;  the  whole  number  of  deaths  being  over 
32,000,  of  which  17,390  were  males,  and  14,709  were 

*  With  reference  to  this  discrepancy,  to  which  I  have  above  adverted,  Mr. 
Sanborn  writes  me  as  follows:  "The  number  discharged  recovered,  after  an 
insanity  of  from  one  to  two  years,  would  naturally  be  greater  than  the  number 
admitted  with  insanity  of  the  same  duration  ;  since  of  those  admitted  with  in- 
sanity of  less  than  one  year's  duration,  a  great  many  are  not  discharged  until 
their  malady  has  continued  beyond  a  year. 

"  With  regard  to  the  want  of  uniformity  in  the  tables  referred  to,  you  must 
remember  that  I  have  not  attempted  to  go  beyond  the  tables  given  by  each  super- 
intendent. That  would  involve  an  amount  of  labor  which  you  can,  doubtless, 
appreciate,  but  which  it  has  not  been  in  the  power  of  this  department  hitherto 
to  perform.  It  is  to  be  regretted  that  the  superintendents  do  not  agree  upon  a 
form  of  statistical  record  which  will  admit  of  perfect  comparisons." 

t  American  Journal  of  Insanity,  April,  1861,  p.  433.  Dr.  Barstow  copies  Le- 
goyt's  error  of  considering  that  these  figures  show  an  advantage  for  the  women 
of  39  per  cent.  I  have,  however,  detected  the  source  of  this  fallacy  in  the  punc- 
tuating of  the  decimals.  Instead  of  .39,  the  calculation  should  have  showed 
.039,  or  between  3  and  4  per  cent.,  which  corresponds  with  the  percentage  I  have 
given  above.  This  decimal  would,  it  is  true,  show  an  excess  of  39  in  every  thou' 
sand,  but  not  in  every  hundred. 


IN    WOMEN.  191 

females.  We  have  here  an  average  deficit  in  favor 
of  the  females,  of  9  per  cent. 

"  How  is  this  diversity  to  be  explained  ?  May  it 
not  be  that  woman,  whose  occupations  are  essentially 
sedentary,  and  whose  habits  more  quiet,  can  accom- 
modate herself  better  than  man  to  the  uniform  system 
and  routine  of  an  asylum  ?  " 

"  This  supposition,"  continues  the  thoughtful  writer 
from  whom  I  have  derived  many  of  the  figures  upon 
which  I  have  reasoned,  "  is  to  a  certain  extent  justi- 
fied by  the  small  number  of  women  who  die  during 
the  first  months  of  their  admission." 

Is  it  not  more  reasonable,  on  the  other  hand,  in 
view  of  correlative  evidence,  to  attribute  these  differ- 
ences to  a  cause  inherent  in  the  fact  of  sex  itself  ? 
These  differences  in  mortality,  it  may,  moreover,  be 
shown,  depend  not  merely  upon  varying  material  and 
economical  appliances  for  treatment,  and  the  varying 
grades  of  society  from  which  patients  are  furnished ; 
but  they  are  constant.  To  prove  this,  let  us  compare 
several  well-known  special  hospitals  for  either  sex. 

At  the  Bicetre,  which  is  exclusively  for  men,  the 
mortality  during  the  nine  years  from  1844  to  1852 
was  263  per  1000.  At  the  St.  Lazare,  which  is  also 
only  for  men,  it  was  during  the  same  period  303  per 
1000 ;  while  at  the  Salpetridre,  which  is  exclusively 
for  women,  the  mortality  during  the  same  period  was 
only  177  per  1000. 


192  REFLEX    INSANITY 

At  the  Worcester  Asylum,  during  its  thirty-two 
years,  there  were  admitted  3503  males  and  3601  fe- 
males, and  died  426  males  and  419  females  ;  in  each 
instance  about  11  per  cent,  of  the  total  admissions. 
From  this  we  should  at  first  sight  surmise  that  the 
mortality  of  the  insane  was  with  us  very  much  lower 
than  it  is  abroad,  did  we  not  compare  also  the  relative 
proportion  of  supposed  recoveries  in  the  two  locali- 
ties. If,  as  we  have  proved,  these  proportions  do  not 
materially  vary,  we  have  reason  to  suppose,  if  the 
history  of  our  cases  were  carefully  followed,  that  their 
mortality  would  not  materially  vary  also.  It  is  in 
questions  like  these,  and  more  especiall}'  in  those  per- 
taining to  the  causation  of  insanity,  as  I  may  show  at 
another  time,  that  statistics  become  so  unreliable.  In 
simple  inquiries  like  those  at  the  commencement  of 
this  discussion,  a  comparison  of  alleged  recoveries 
with  the  number  of  alleged  admissions,  for  instance, 
there  is  less  opportunity  for  error,  though  even  here, 
as  will  soon  be  seen,  there  is  abundant  cause  for 
doubt.  The  more  complicated  the  question  becomes, 
the  more  unreliable  the  result  from  statistics.  As 
these  have  been  called  for,  however,  I  desire  that  they 
should  not  be  withheld. 

In  this  connection,  I  may  be  pardoned  for  present- 
ing some  very  pertinent  remarks  upon  the  subject 
from  an  authority  whose  loss  is  yet  fresh  to  us  in 
Massachusetts. 


IN    WOMEN.  193 

At  the  tenth  annual  meethig  of  the  Association  of 

Medical  Superintendents  of  American  Institutions  for 

tlie  Insane,  held  at  Boston,  in  May,  1S55,  Dr.  Bell 

observed  that  — 

"  He  had  seen  no  reason  to  change  the  views  urged  by 
him  so  many  years  ago  in  reference  to  the  worthlessness  and 
inexpediency  of  attempting  to  present  the  facts  of  our  hos- 
pitals for  the  insane  in  a  numerical  form.  For  many  years 
he  had  protested  against  it,  both  as  producing  unjust  infer- 
ences as  to  different  institutions,  and  untrue  expectations  in 
the  public  mind.  He  had  labored  to  effect  a  change  in  this 
matter,  and,  he  believed,  not  without  success.  In  fact,  he 
had  rendered  himself  somewhat  notorious,  at  one  time,  he 
feared,  by  his  annual  diatribe  against  the  existing  system  of 
reporting.  When  visiting  the  most  excellent  institution  at 
York,  in  England,  '  Art  thou  the  Luther  V.  Bell  who  has 
written  so  severely  about  the  statistics  of  the  insane.'"  was 
the  salr.tation  which  preceded  every  attention  and  kindness 
rhich  the  distinguished  host  could  gife  his  visitor.  The 
lifficulties  he  feared  were  in  the  very  nature  of  the  sub- 
lect.  One  would  think  that  the  fact  of  a  patient  being  dead, 
for  instance,  was  as  specific,  unconfoundable  a  basis  for  a 
statistical  return  as  could  be  conceived  of;  yet  he  would  en- 
gage to  make  his  returns  of  dead  vary  fifty  per  cent.,  without 
one  deviation  from  truth.  A  simple  suggestion  to  friends, 
that  it  might  be  more  agreeable  to  them  that  the  last  days 
of  a  failing  patient  should  be  spent  in  the  bosom  of  his  fam- 
ily, would  very  frequently  decide  whether  a  case  of  death 
should  be  on  the  annual  return."  * 

At  a  subsequent  meeting  of  the  Association,  Dr. 

Tyler,   Dr.  Bell's  equally  eminent   successor  at  the 

McLean  Asylum,  took  occasion  to  state  that,  though 

statistics  might  not  lie,  "  still  we  know  that  the  mor- 

*  American  Journal  of  Insanity,  xii.  p.  90 
13 


194  REFLEX   INSANITY 

tals  that  make  figures  sometimes  do."  *  Without  in 
any  way  implying,  or,  indeed,  believing,  that  this 
view  of  Dr.  Tyler's  is  especially  applicable  to  the 
point  we  are  now  considering,  for  the  statistics  that  I 
have  given  were  undoubtedly  published  in  perfectly 
good  faith  by  their  collators,  I  may  yet  call  attention 
to  the  peculiar  force,  in  the  present  connection,  of  the 
last  remark  of  Dr.  Bell. 

Similar  comments  are  as  applicable  to  the  reports 
afforded  of  death  details.  •'  I  do  not  see,"  says  Dr. 
Ray,  "  how  we  can  put  forth  as  facts,  of  any  statisti- 
cal importance,  the  apparent  causes  of  death.  It  is 
the  custom  to  publish  in  the  reports  of  the  institution 
the  cause  of  death.  Now,  everybody  knows  that  in 
many  cases  this  must  be  a  matter  of  guess-work.  I 
should  have  far  less  confidence  in  the  guess  of  any 
man  in  regard  to  the  cause  of  death  in  an  insane  per- 
son, than  in  one  not  insane."  f 

To  return  to  the  discussion.  We  may,  then,  justly 
consider,  from  the  evidence  that  has  been  afforded, 
that  "  in  those  establishments  which  are  devoted  ex- 
clusively to  females,  the  mortality,  other  things  being 
equal,  should  be  found  less  than  in  t\  ose  devoted  ex- 
clusively to  males,  the  probabilities  of  death  being,  as 
we  have  already  seen,  greater  among  the  latter."  J 

This  fact  is  corroborated  by  Dr.  Lockhart  Robert- 


*  American  Journal  of  Insanity,  July,  1862,  p.  44. 

t  Ibid,  July,  1862,  voL  xii.  p.  38.  t  Legoyt,  loc  dt,  p.  437. 


IN   WOMEN. 


195 


son,  superintendent  of  the  Sussex  Asylum,  who  says 
that  "  the  mean  annual  mortality  of  the  male  sex 
among  the  insane  exceeds  that  of  the  female  by  about 
35  per  cent.,  while  among  the  general  population  the 
male  mortality  only  exceeds  the  female  by  8  per 
cent."  *  This  last  excess,  it  will  be  perceived,  corre- 
sponds almost  exactly  with  the  normal  rate  of  dispro- 
portion in  the  sexes,  which,  estimated  by  Qi'^telet  as 
averaging  106  male  births  alive  to  100  females  in 
Europe,  has  been  shown  by  Dr.  Emerson,  of  Phila- 
delphia, in  his  excellent  paper,  formerly  presented  to 
this  Association,  to  vary  in  this  country  from  107  to 
no  males  to  100  females.f 

There  is  also  a  difference  in  the  progressive  mor- 
tality of  the  two  sexes,  according  to  age.  Thus, 
from  a  tabular  exposition  of  the  ages  at  which  3303 
patients  deceased  in  the  French  asylums,  of  whom 
1755  were  males  and  1548  females,  it  appears  that  of 
females  at  insane  hospitals  dying  under  fourteen  years, 
there  are  92  per  cent,  as  many  as  men. 

From  14  to  20  years, 

"  20  to  25 

"  25  to  30 

"  30  to  35 

"  35  to  40 

"  40  to  50 

"  50  to  60 


57  pe 

r  c 

63 

73 

64 

65 

60 

90 

*  Notes  on  the  Prognosis  in  Mental  Disease,  Asylum  Journal  of  Mental  Sd« 
ence,  January,  1859,  p.  287. 
t  Transactions  of  American  Medical  Association,  vol.  iii.  p.  93. 


196  REFLEX    INSANITY 

These  differences  are  attributed  by  Legoyt  to  "  the 
greater  vitality "  of  the  female  sex.  With  reference 
to  the  same  point,  evidence  concerning  the  relative 
vitality  of  patients  considered  incurable  is  not  irrel- 
evant. 

The  following  table  is  given  by  Dr.  Jarv'is  as  the 
probable  duration  of  life  in  irrecoverably  insane  per- 
sons. It  is  based  upon  a  calculation  of  the  expecta- 
tion of  life  in  the  insane,  made  by  the  actuary  of  an 
English  Life  Assurance  Company  :  —  * 


Age. 

Males. 

Females. 

20 

21.31  y 

ears  to  live. 

28.66  years  to  live. 

30 

20.64 

26.33 

40 

17-65 

21.53 

50 

13-53 

17.67 

60 

1 1. 91 

12.51            " 

70 

9-15 

8.87 

Or,  in  other  words,  the  insane  woman  at  twenty, 

supposed  incurable,  has  1.31  per  cent,  as  many  years 

to  live  as  the  insane  man. 

At  30, 1.23  per  cent. 

"40, 1.07       " 

"50, 1-30       " 

"60, 1.05       " 

"70, 88 

From  these  facts  it  appears,  and,  as  will  have  been 
seen,  is  acknowledged  by  competent  authority,  that  — 

I.  The  relative  mortality  of  insane  women  is  less 
than  of  insane  men. 

•  Appendix  to  Report  to  Leg.  of  Mass.,  1855,  p.  19a. 


IN   WOMEN.  197 

2.  Their  expectation  of  life,  even  when  supposed 
incurable,  is  greater  ;  and 

3.  Their  percentage  of  recoveries,  even  when  the 
mental  disturbance  has  become  chronic,  is  also  in 
excess. 

But  how  does  this  evidence  affect  the  question  as  to 
whether  the  recoveries  of  women  at  asylums  are 
cures  ? 

In  several  ways. 

In  both  sexes,  many  patients  are  sooner  or  later  re- 
admitted to  the  hospital,  their  disease  proving  to  have 
been  merely  palliated,  not  cured. 

The  remedial  discipline  to  which  the  two  sexes  are 
subjected  at  asylums  is  almost  identical.  It  is  chiefly 
that  which  is  called  moral ;  the  medical  treatment 
in  almost  every  instance  being  of  a  strictly  general 
character.  We  are,  therefore,  compelled  to  one  of 
two  alternatives,  not  that  more  women  recover  at 
asylums  than  men,  for  this  is  beyond  what  has  been 
claimed,  or  what  statistics  prove,  but  that  either  a 
certain  larger  proportion  of  insane  women  do  not  die 
at  hospitals  than  men,  and  do  recover  from  chronic 
insanity  under  the  same  general  treatment,  which  is 
shown  by  statistical  evidence,  and  which  must  arise 
from  some  primal  difference  in  causation  ;  or  else  that 
the  character  of  their  insanity  is  different,  and  this  also 
implies  a  difference  of  cause,  not  of  moral  and  excit- 
ing causes  merely,  for  these  on  the  great  scale  and  in 


198  REFLEX  INSANITY 

different  countries  will  be  found  to  be  nearly  the  same, 
the  excesses  in  the  one  instance  counterbalancing  all 
deficiencies  in  another,  but  of  an  intrinsic  and  physical 
character,  probably  sexual. 

Now  it  will  be  found  that  those  writers  who  deny 
the  existence  of  a  different  physical  causation  of  in- 
sanity in  the  two  sexes,  are  no  better  prepared  to 
accept  the  other  horn  of  this  dilemma,  for  it  will  be 
found  that  a  different  result  from  the  same  general 
treatment  implies  a  difference  in  disease ;  and  a  dif- 
ference in  disease  arising  from  the  excitement  of  simi- 
lar stimuli,  implies  a  difference  in  predisposition,  and 
therefore,  in  ultimate  causation. 

The  only  escape  from  these  conclusions,  is  by  de- 
nying my  premises  as  to  the  character  and  identity 
of  the  medical  treatment  resorted  to  for  the  two  sexes. 
Upon  this  point,  however,  though  I  have  already 
furnished  sufficient  evidence,  I  will  add  still  more. 

Again,  most  writers  on  insanity  acknowledge  a 
frequent  influence  of  the  catamenia  and  of  the  cata- 
menial  molimen  in  reference  to  the  exacerbation  of 
the  mental  disturbance ;  this,  to  a  certain  extent,  put- 
ting aside  the  question  as  to  whether  or  no  the  in- 
sanity in  any  of  these  cases  springs  from  a  uterine 
origin.  To  the  extent  now  stated,  few  will  deny  the 
fact,  for  an  immense  body  of  proof  has  been  inci- 
dentally published  in  psychological  text  books,  mono- 
graphs, and  periodicals,  and  can  be  readily  adduced, 


IN  WOMEN.  199 

In  many  of  these  cases,  the  menses  when  absent  have 
accidentally  appeared  without  any  direct  aid  from 
medical  treatment,  and  the  patient  has  immediately 
and  in  consequence  recovered.  Such  cases  are  not 
spoken  of  as  uncommon.  They  undoubtedly  fre- 
quently occur. 

Many  instances  are  also  on  record,  where  insanity 
has  suddenly  ceased  on  the  woman's  passing  the  grand 
climacteric,  at  the  permanent  and  final  cessation  of 
the  catamenia.  It  could  hardly  be  alleged  that  these 
were  cases  of  cure.  They  also,  there  is  good  reason 
to  believe,  are  not  uncommon. 

It  will  be  seen  that  I  here  purposely  avoid  referring 
to  other  than  published  and  acknowledged  evidence 
furnished  by  the  directors  of  asylums,  for  almost  every 
work  as  yet  issued  upon  the  subject  of  insanity  has 
been  from  such  a  source. 

There  is  one  other  point  to  which,  in  this  connec- 
tion, I  may  be  permitted  to  refer,  and  that,  the  com- 
parative infrequency  in  women  of  one  of  the  most  com- 
mon and  most  fatal  of  the  forms  of  insanity.  I  refer 
to  the  so-called  paralysis  of  the  insane,  the  paralysie 
generale  of  the  usual  and  artificial  classification. 

This  disease,  one  of  the  few  mental  disorders  that 
is  attended  by  organic  lesion  of  the  brain,  or  rather 
of  the  medulla  oblongata  and  spinal  cord,  is  com- 
paratively unknown  in  women.  This  fact  has  been 
acknowledged  by  Dr.  Robertson,  of  the  Sussex  Asj^- 


200  REFLEX    INSANITY 

lum,*  by  Drs.  Workman  and  Choatef  in  this  country, 
and  by  many  other  competent  authorities.  "  We 
know  positively,"  says  Morel,  "  that  the  number  of 
the  (general)  paralytic  insane  is  infinitely  greater 
among  men  than  among  women."  J 

In  a  table  furnished  by  the  author  now  quoted,  it 
appears  that  of  Soo  insane  women  at  the  asylum  of 
St.  Yon,  there  were  25  afflicted  with  this  disease,  or 
3  per  cent. ;  while  at  the  asylum  of  Quatre  Mares, 
devoted  exclusively  to  males,  there  were  of  500  in- 
mates no  less  than  100,  or  20  per  cent.,  affected  with 
general  paralysis. 

It  is  undoubtedly  this  disease  that  was  referred  to 

by  Esquirol,  when  he  says, — 

"  Paralysis  is  more  frequent  among  insane  men  than 
women.  Eighteen  years  ago,  when  charged  with  the  service 
of  the  division  of  the  insane  at  the  Bicctre,  during  the  ab- 
sence of  M.  Pariset,  who  was  sent  to  Cadiz  to  study  the 
yellow  fever  which  was  prevailing  there,  I  was  struck,  in 
comparing  the  number  of  men,  insane  and  paralytic,  at  the 
Bict'tre,  and  the  number  of  paralytic  women  at  the  Sal- 
petriere.  The  same  observation  may  be  made  in  every 
establishment  into  which  both  sexes  are  admitted.  It  has 
not  escaped  the  notice  of  Dr.  Foville.  physician-in-chief  at 
St.  Yon.  According  to  this  physician,  they  amount  to  one 
eleventh  at  the  institution  over  which  he  presides.  Among 
334  insane  persons  who  were  examined  by  him,  31  were 
paralytic,  to  wit,  22  men  and  9  women.  At  Charenton,  the 
proportion  of  paralytics  is  still  more  considerable.  They 
constitute  one  sixth  of  the  whole  number  of  admissions.    In 

•  Asylum  Journal  of  Mental  Science,  January,  1859,  p.  276. 
t  American  Journal  of  Insanity,  i860. 
t  Traite  des  Maladies  Mentales,  p.  813. 


IN   WOMEN.  20I 

truth,  of  619  insane  persons  who  were  admitted  during  the 
three  years,  I826,  1827,  and  1828.  109  were  paralytics.  But 
the  proportion  of  men  is  enormous  compared  with  that  of 
women.  Of  366  insane  men  admitted  into  the  house,  95 
were  paralytics;  while  of  153  women,  14  only  w^ere  affected 
with  paralysis.  This  complication  is  most  frequently  ob- 
served among  that  class  of  insane  persons  who  have  yielded 
to  venereal  excesses,  or  have  been  addicted  to  the  use  of 
alcoholic  drinks;  among  those,  also,  who  have  made  an  in- 
ordinate use  of  mercurj',  as  well  as  those  who,  exercising  the 
brain  too  vigorously  in  mental  strife,  have  at  the  same  time 
abandoned  themselves  to  errors  of  regimen.  Do  not  these 
circumstances  explain  sufficiently  well  how  it  happens  that 
there  are  more  men  insane  and  paralytic  than  women.?"* 

The  few  cases  of  women  who  are  affected  by  gen- 
eral paralysis  are  chiefly  prostitutes,!  so  that  in  the 
ordinary  classes  of  society,  it  is  among  women  prac- 
tically absent.  The  fact  to  which  I  have  referred  is 
one  that  is  now  generally  acknowledged.  In  a  dis- 
cussion upon  the  subject  at  Philadelphia,  in  i860,  it 
was  fully  admitted  by  Drs.  Workman  of  Toronto, 
Bancroft  of  the  New  Hampshire  State  Asylum,  Athon 
of  that  of  Indiana,  and  Harlow  of  that  of  Maine.  J 

The  same  comparative  immunity  for  women  has 
also  been  noted  in  the  form  of  insanity  now  known  as 
congestive  mania,  and  so  thoroughly  described  by  my 
colleague,  Dr.  Worthington,  of  the  Friends'  Asylum 
at  Frankford,  Pa.§ 


*  Esquirol,  loc  dt,  p.  438. 

t  Morel :  Traites  d<  s  Maladies  Mentales,  p.  828. 
t  American  Journal  of  Insanity,  July,  i860,  p.  65. 
§  Ibid,  p.  64.  —  Oaober,  1850,  p.  X14. 


202  REFLEX    INSANITY 

We  may,  from  the  evidence  that  has  now  been 
offered,  foirly  conclude,  that  (i)  while  some  at  least 
of  the  women  discharged  from  asylums  as  recovered, 
are  not  in  reality  cases  of  cure,  (2)  there  are  others 
not  reported  as  having  recovered,  who  yet  ought,  if 
we  may  believe  the  evidence  of  statistics,  to  have  done 
so.  If  the  mortality  in  insane  women  is  less  than  in 
men,  and  if  the  most  frequent  of  the  incurable  mental 
diseases  in  men  is  absent  in  women,  a  larger  per- 
centage of  them  should  recover  than  of  men,  unless 
they  have  some  corresponding  fatal  disease  which  is 
absent  in  men.  The  existence  however  of  such  a  dis- 
ease has  never  been  acknowledged. 

If  the  facts  above  proved  are  admitted,  it  would 
seem  (3)  that  all  justifiable  resources  of  medical  treat- 
ment can  scarcely  have  been  put  in  requisition  at 
asylums. 

I  have  alluded,  in  connection  with  the  last  point 
now  referred  to,  to  the  admissions  of  gentlemen  having 
asylums  in  charge.  In  a  former  communication  upon 
this  subject,  I  stated  why  it  was  that,  as  asylums  are 
now^  constituted,  the  whole  duty  of  a  physician  by  his 
patient,  if  a  woman,  could  not  be  performed.*  The 
evidence  was  such  as  was  thought  conclusive  by  the 
American  Medical  Association,  at  its  late  meeting  in 
New  York.  That  there  might  be  no  room  for  cavil, 
I  fortified  my  arguments  by  a  frank  and  forcible  letter 

*  Boston  Medical  and  Sui^cal  Journal,  October,  1864,  p.  311. 


IN   WOMEN.  203 

from  Dr.  Butler,  of  the  Hartford  Retreat.*  The  force 
of  this  letter  was  subsequently  sought  to  be  weak- 
ened, by  the  assertion  '^that  it  was  only  conclusive 
of  the  lack  of  a  disposition  on  the  part  of  its  writer 
to  make  use  of  all  the  means  of  treatment  considered 
proper  to  aid  in  restoring  a  patient."  f  That  the 
position  of  Dr.  Butler,  as  described  by  himself,  is  a 
very  common  one,  I  have  good  reason  to  believe.;  and 
as  it  arises  from  causes  over  which  superintendents 
have  had  no  control,  I  have  not  been  so  unjust  as  to 
throw  any  blame  upon  them,  as  their  own  official 
brother  seems  to  have  done  in  the  communication  to 
which  I  have  referred. 

The  same  charge  of  incompetence,  implied  if  not 
directly  made,  against  these  gentlemen,  has  come  to 
me  from  another  quarter  of  their  own  precincts. 
Under  date  of  nth  January,  1865,  Dr.  Gray,  of  the 
New  York  State  Lunatic  Asylum  at  Utica,  writes  me 
as  follows :  — 

"  Of  the  applicability  of  some  of  your  strictures  to  some 
asylum  superintendents, J  it  is  not  for  me  to  judge.  I,  how- 
ever, contend  that  they  do  not  apply  to  all,  any  more  than 
would  a  sweeping  charge  of  ignorance  against  the  medical 
faculty  of  Harvard,  on  account  of  the  incapacity  of  some  of 
your  professional  brethren."  § 

*  Boston  Medical  #nd  Surgical  Journal,  October,  1864,  p.  214. 

t  Ibid.,  November,  1864,  p.  290. 

t  It  will  have  been  noticed  by  those  familiar  with  my  former  papers,  that  my 
strictures  were  upon  no  asylum  superintendents,  but  upon  the  circumstance! 
which  prevent  their  performing  their  whole  duty  by  their  patients. 

§  Had  Dr.  Gray  the  gift  of  prophecy?  might  now,  in  1870^  well  be  asked. 


204  REFLEX    INSANITY 

I  can  only  say,  in  reference  to  this  point,  that  the 
only  instances  in  which  evidence  has  been  furnished 
me  that  what  is  generally  styled  special  treatment  for 
the  diseases  peculiar  to  women,  such  as  is  now  con- 
stantly resorted  to,  and  generally  considered  proper 
and  necessary  in  civil  practice,  has  ever  been  em- 
ployed at  any  of  our  insane  asylums,  save  at  the 
Butler  Hospital,  at  Providence,  and  at  the  McLean 
Asylum,  in  consultation,  have  been  at  the  Friends' 
Hospital,  at  Frankford,  Pa.,  and  at  the  Michigan  State 
Asylum,  at  Kalamazoo,  respectively  under  the  charge 
of  my  colleagues,  Drs.  Worthington  and  Van  Dcusen. 
I  may  in  this  matter  do  great  injustice  to  the  zeal  of 
those  eminent  in  this  specialty,  and  to  their  moral 
courage,  for  this  is  needed  in  instituting  what  I  have 
proved  to  be  a  radical  change  in  treatment,  but,  as  I 
have  made  minute  inquiries,  and  have  now  heard 
from  many  of  the  gentlemen  referred  to,  it  is  hardly 
possible. 

In  the  case  of  the  Utica  Asylum,  from  which  one 
of  the  implications  alluded  to  has  come,  I  can  only 
say  that  this  is  one  of  quite  a  number  of  asylums  that 
I  have  had  opportunity,  officially,  carefully  to  exam- 
ine ;  that  my  visit  to  it  was  in  September,  1863  ;  that 
in  the  absence  of  Dr.  Gray,  the  superintendent,  I  was 
most  courteously  received  by  his  very  intelligent  as- 
sistant physicians,  who  freely  and  fully  informed  me 
concerning  all  points  that  I  raised,  which  were  chiefly 


IN   WOMEN.  205 

with  reference  to  the  medical  treatment  of  the  female 
patients  ;  that  from  what  I  was  told,  I  have  no  reason 
to  suppose  that  special  treatment  was  thought  neces- 
sary at  that  asylum  for  the  so  common  special  diseases 
of  women,  whether  occurring  as  cause  of  the  insan- 
ity, or  its  concomitant ;  and  that  I  had  very  good  rea- 
son, on  the  contrary,  to  believe  that  such  was  seldom 
or  never  resorted  to  at  the  present  time.*  If,  how- 
ever, 1  was  mistaken  in  my  impression,  —  and  I  shall 
be  most  happy  to  learn  that  I  was  in  error,  —  then  it 
will  follow  that  Dr.  Gray  himself,  and  all  gentlemen 
who  are  sufficiently  enlightened  to  engage  in  the  in- 
vestigations for  which  I  am  contending,  and  which, 
from  the  language  I  have  quoted,  he  would  seem  to 
approve,  it  will  follow  that  they  all,  equally  with  my- 
self, fall  under  the  ban  laid  in  the  Boston  Medical  and 
Surgical  Journal  for  5th  January,  1865,  upon  every 
one  of  us  who  would  cure  in  insane  women  tlieir  so- 
called  "  imaginary  "  physical  disease  ;  f  as  supposed 
to  be  present,  not  by  them,  but  by  ourselves. 

I  have  said  that  my  remarks  do  not  apply  to  our 
own    asylums    alone,   nor   have  I  desired   that   they 

*  Yet  in  the  report  of  the  New  York  State  Asylum  for  1852,  by  Dr.  Gray,  it 
appears  that  in  nearly  one  fourth  of  all  the  cases  of  insanity  reported,  the  dis- 
turbance of  the  generative  organs  was  so  marked  as  to  be  regarded  as  71  primary 
cause  of  the  mental  derangement.  (Amer.  Journal  of  Insanity,  xii.  p.  306.) 
In  the  report  of  the  same  institution  ten  years  later,  for  1862,  only  a  tenth  of  the 
women  are  thus  reported,  unless  the  forty-three  cases  stated  as  caused  by  pre- 
vious ill  health  are  to  be  considered  of  this  character,  in  wliich  event,  tlia 
proportion  would  rise  to  nearly  one  hal£ 

t  Loc.  cit.,  pp.  453  and  453. 


2o6  REFLEX   INSANITY 

should  seem  to  do  so.  The  similarity  as  to  percent- 
ages of  recoveries,  &c.,  between  our  own  and  for- 
eign asylums,  goes  to  prove  what  I  have  attempted 
to  show  by  other  evidence,  that  nowhere,  at  home  or 
abroad,  has  the  difference  of  causation  which,  I  be- 
lieve, exists  in  many  instances  between  the  two  sexes 
as  to  mental  disease,  been  generally  appreciated  or 
acted  upon.  The  view  to  which  I  refer  explains  the 
problems  elicited  by  the  statistics  I  have  now  pre- 
sented ;  the}',  on  the  other  hand,  are  wholly  inexpli- 
cable, save  by  this  simple  key.  I  may  be  told  over 
and  over  again  that  my  view  is  an  old  one.  If  appre- 
ciated in  all  its  bearings,  why  then  has  it  not  been 
accepted  ?  That  it  has  been  so  in  the  present,  or  in 
former  times,  I  can  find  no  evidence. 

The  disturbance  which  my  deductions  seem  to  have 
caused  in  certain  minds,  would  seem  to  imply,  as  I 
have  indeed  been  told,  that  there  was  a  chance  that 
these  inquiries,  if  pushed,  would  result  in  injuiy  to 
the  present  unimpeded  system  of  hospital  manage- 
ment. Nothing,  however,  as  I  have  already  asserted 
in  almost  every  paper  I  have  written  upon  the  sub- 
ject, is  further  from  my  own  intention.  The  re- 
searches have  been  undertaken  simply  and  solely  for 
a  scientific  purpose,  and  the  papers  I  have  now  pre- 
sented may  serve  as  earnest  that  the  investigations 
will  be  pushed  to  their  legitimate  result,  it  is  almost 
unnecessary  to  state,  without  either  fear  or  favor. 


IN   WOMEN.  207 

It  was  lately  publicly  intimated,  that  for  one  of  the 
measures  I  have  advocated,  merely  one  item  in  the 
system  of  public  and  private  treatment  that  is  re- 
quired for  insane  women,  the  establishment  of  an 
Advisory  Medical  Board  at  asylums,*  there  can  be 
found  no  one  of  any  note  among  superintendents  to 
approve.  I  will  not  weary  my  readers  by  carrying 
my  evidence  from  statistics  to  any  greater  extent  than 
I  have  already  done,  though  I  am  well  prepared  even 
upon  this  point.  I  will,  therefore,  simply  append  the 
following  letter,  which  was  unsolicited,  from  Dr. 
Isaac  Ray :  — 

"Butler  Hospital,  Nov.  26,  1864. 

"  My  dear  Sir  :  I  have  read  your  pamphlet  with  much 
interest,  especially  your  remarks  on  the  employment  of 
Boards  of  Consulting  Physicians  in  asylums  for  the  insane. 
Your  views  strike  me  to  be  eminently  just,  and  I  am  glad 
you  have  called  public  attention  to  the  subject.  The  case, 
in  fact,  hardly  admits  of  argument.  What  medical  man 
now  needs  be  persuaded  that  in  a  hospital  of  at  least  one 
hundred  patients,  for  any  disease,  there  must  be  occasions, 
more  or  less,  when  the  single  doctor  in  charge  would  or 
should  gladly  consult  another  physician.?    And  if  so,  it  is 

*  Trans.  Amer.  Med.  Association,  1864.  With  regard  to  the  suggestion  now 
referred  to,  I  would  frankly  state  that  my  colleagues,  Drs.  Van  Deusen  and 
Worthington,  like  some  others  of  the  fraternity  who  have  erroneously  seen  in 
the  advisory  board  an  end  rather  than  a  means,  are  disinclined  to  indorse  it ; 
basing  their  oLjections,  so  far  as  communicated  to  me,  upon  the  trite  ground  th  < 
any  assistance  would  be  rather  an  interference  with  the  superintendents.  The 
former  of  the  gentlemen,  however,  admits  that  "the  subject  of  the  appointment 
of  a  consisting  physician  and  surgeon,  with  special  reference  to  the  examination 
and  surgical  treatment  of  female  patients  requiring  it,  is  new"  to  him;  and  it  is 
allowed  by  the  latter  that  "  there  might  be  cases,  here  and  there,  that  would 
(thus)  be  helped." 


2o8  REFLEX    INSANITY 

far  better  that  he  should  resort  to  an  established  Board, 
made  expressly  for  his  benefit,  ready  to  come  gratuitously, 
than  to  some  eminent  man  who  expects  and  is  justly  entitled 
to  a  liberal  compensation.  To  such  a  Board  as  I  refer,  the 
honor  of  the  position  would  always  be  considered  sufficient 
compensation  for  so  light  a  duty. 

*'  Your  paper  seems  to  be  but  part  of  a  larger  one,  which, 
if  published,  I  have  not  been  so  fortunate  as  to  meet.  Un- 
questionably, abnormal  conditions  of  the  sexual  organs  have 
often  a  very  large  influence  in  the  development  of  insanity 
in  women.  I  presume,  however,  my  observations  would 
hardly  warrant  me  in  attributing  so  much  to  them  as,  I  sup- 
pose, from  one  or  two  expressions,  you  do. 

*'  I  admit  that  we  asylum  physicians  cannot,  necessarily, 
obtain  that  accuracy  of  diagnosis  which  is  comparatively 
easy  to  other  men;  but  the  existence  of  sexual  disorder  of 
some  kind  need  not  be  overlooked  by  any  one  who  looks  at 
all,  provided  it  is  sufficiently  grave  to  affect  the  brain.*  Not 
that  I  consider  these  affections  as  of  little  consequence,  and 
unworthy,  when  present,  of  being  accurately  understood 
and  properly  treated,  for  I  am  well  aware  that  mental  dis- 
ease may  sometimes  be  continued  indefinitely  by  the  persist- 
ent influence  of  sexual  organic  disorder. 

"  We  had  here  this  summer  a  death  in  the  earlier  stage 
of  mania,  where  the  disease  seemed  to  have  been  mainly 
excited  by  some  venereal  excrescences  in  the  vagina,  and  we 
have  now  in  the  house  a  lady  whose  disease  was  unquestion- 
ably produced,  as  it  is  now  kept  up.  by  an  '  irritable  uterus.' 

"I  repeat  that  I  am  glad  you  have  called  attention  to  this 
point,  because,  in  the  treatment  of  insanity,  we  are  too  apt 
to  overlook  or  undervalue  all  collateral,  subordinate  condi- 
tions. 

"Yours,  very  respectfully, 

"  I.  RAY. 

"Dr.  H.R.  Storer." 

•  Dr.  Ray  seems  here  hardly  to  appreciate  the  nice  discriminations,  so  often 
productive  of  success  in  treatment,  now  made  in  the  diagnosis,  direct  and  differ* 
ential,  of  pelvic  disease. 


IN    WOMEN.  209 

The  following  is  the  Report  above  alluded  to :  — 

"In  late  communications  to  the  American  Academy  of 
Arts  and  Sciences,  and  to  the  Suffolk  District  Medical  So- 
ciety of  Massachusetts,*  I  have  stated  certain  fundamental 
propositions  or  laws,  whose  acceptance  is  essential  to  any 
rational  explanation  or  treatment  of  the  mental  diseases  of 
women.     These  propositions  are  as  follows  :  — 

"I.  That  in  women  mental  disease  is  often,  perhaps  gen- 
erally, dependent  upon  functional  or  organic  disturbance  of 
the  reproductive  system. 

"II.  That  in  women  the  access  or  exacerbation  of  mental 
disease  is  usually  coincident  with  the  catamenial  establish- 
ment, its  periodical  access,  or  final  cessation. 

"III.  That  the  rational  and  successful  treatment  of  men- 
tal disease  in  women  must  be  based  upon  the  preceding  the- 
ories, which  I  claim  are  established,  — 

"  I.  By  many  analogies,  physiological  and  pathological, 
in  the  cerebral  manifestations  of  the  human  female  and  of 
the  lower  mammals; 

"2.  By  clinical  observation  ;  and 

"3.  By  the  results  of  autopsies  of  the  insane,  both  in 
private  practice  and,  where  made  with  equal  impartiality,  in 
insane  asjdums. 

"  I  have  worded  the  last  expression  with  especial  reference 
to  the  facts,  that  in  autopsies  by  psychological  specialists 
diseases  of  the  brain  are  naturally  those  first  sought  for; 
and  that  in  autopsies  of  insane  women,  as  compared  with 
those  of  insane  men,  disease  of  the  brain,  as  a  primary  le- 
sion, very  rarely  exists.  These  facts  are  acknowledged;  for 
further  remarks  upon  them  I  must  refer  to  the  preliminary 
paper  to  which  I  have  already  alluded. 

"  From  the  above  propositions,  corroborated,  I  believe, 
by  the  experience  of  every  unbiassed  observer,  we  advance 
to  three  plain  and  practical  questions,  which  are  to  open  up 

*  Boston  Medical  and  Surgical  Journal,  April,  1864,  p.  189. 


2IO  REFLEX   INSANITY 

a  new,  broad,  and  very  fruitful  field  of  gynaecological  work 
These  are,  — 

"  I.  To  what  extent  can  the  insanity  of  women  be  medi- 
cally or  surgically  treated  ? 

"  2.  Is  such  treatment  at  present  generally  effected,  or 
even  attempted,  in  insane  hospitals?  and,  — 

"  3.  How  can  it  there  be  accomplished? 

"  I  am  aware  that  I  have  broached  a  delicate  topic.  The 
comparison,  however,  of  doubtfully  insane,  of  almost  insane, 
and  of  decidedly  insane  women,  in  all  their  range,  from  ag- 
gravated hysteria  to  actual  madness,  has  so  long  been  my 
daily  occupation  that  I  am  enabled  to  express  myself  plainly 
upon  this  subject.  It  is  one  that  has  been  hitherto  neglect- 
ed, for  the  sole  reason  that  its  proper  side  of  approach  —  that 
from  a  gynaecological  point  —  happens,  from  circumstances 
beyond  their  control,  almost  always  to  have  been  closed  to 
superintendents  and  others  charged  with  the  management 
of  the  insane- 

"  The  first  question  that  I  have  now  proposed,  To  what 
extent  can  the  insanity  of  women  be  medically  and  surgi- 
cally treated?  has  as  yet  hardly  been  propounded  in  insane 
asylums  at  all,  although  its  solution  in  active,  everyday 
practice  is,  within  certain  limits,  of  common  enough  occur- 
rence. I  have  purposely  limited  my  statement  of  the  extent 
to  which  this  treatment  has  as  yet  been  carried  in  private 
practice.  Instances  in  point,  however,  —  the  ordinary  forms 
of  the  so-called  puerperal  mania,  and  of  that  other  type  of 
insanity  to  which  in  its  different  manifestations  I  would  at- 
tach the  equally  legitimate  title  of  catamenial  mania,  —  are 
familiar  to  every  observer.  In  these  and  in  others  of  the 
host  of  deviations  from  mental  sanity  in  women,  there  is 
some  reflex  transferrence  of  irritative  action,  the  source  of 
which,  if  searched  for,  is  almost  always  to  be  discovered. 
It  is  just  as  unscientific  here,  and  generally  as  futile,  to  treat 
merely  or  primarily  the  mental  disturbance,  which  is  usually 
a  symptom  only  or  a  consequence,  as  it  has  been  to  ampu- 
tate an  hysterical  knee,  to  attempt  the  Caesarean  section  or 
to  cut  for  ovariotomy  in  cases  of  the  so-called  spurious  preg- 


IN    WOMEN.  211 

nancy,  or,  as  is  still  constantly  done,  even  at  the  present  day, 
to  stimulate  or  blister,  or  apply  the  moxa  or  actual  cautery 
to  spines  irritated  sympathetically  and  through  reflex  action 
by  an  abraded,  displaced,  or  otherwise  disturbed  womb.  The 
necessity  of  removing  a  cause,  to  prevent  or  to  cure  its  eftect, 
is  as  decided  in  mental  pathology  as  in  physical.  We  recog- 
nize it  everywhere  else ;  we  must  recognize  it  in  the  treat- 
ment of  insane  women,  no  matter  whether,  from  quiet  and 
inoffensive  creatures,  or  chaste  and  pure,  they  have  become 
habitually  thievish,  profane,  or  obscene,  despondent  or  self- 
indulgent,  shrewish  or  fatuous,  or,  as  the  parturient  cat  or 
sow,  they  have  destroyed  their  offspring,  or,  in  other  cases, 
have  attempted  to  destroy  themselves. 

"  In  many  of  these  instances,  the  relation  of  cause  to  effect, 
if  otherwise  doubtful,  is  at  once  shown  by  the  result  of  the 
treatment.  I  might  relate  many  cases  in  illustration  of  this 
fact  from  my  own  experience,  but  shall  confine  myself  to  a 
single  one. 

"  Case.  During  the  past  year  I  have  had  charge  of  a 
young  lady  afflicted  with  that  not  uncommon  disease,  me- 
chanical dysmenorrhoea.  This  patient,  unmarried,  and  for- 
merly a  school-teacher,  was  sent  to  me  by  a  physician,  and 
had  previously  consulted  several  others.  She  confessed  to 
me  that  while  she  never  had  had  sexual  intercourse,  she  had 
experienced,  from  a  period  long  preceding  her  first  seeking 
medical  aid,  excessive  sexual  desire,  amounting,  indeed,  to 
what  is  technically  termed  nymphomania — a  symptom 
merely,  as  are  most  of  the  mental  disturbances  of  women. 
The  attacks  of  this  were  very  clearly  coincident  with  the 
menstrual  period,  and  so  extreme  that  the  patient  could  with 
difficulty  restrain  herself  from  soliciting  the  approach  of  the 
other  sex.  She  could  not  restrain  herself  from  frequent  and 
excessive  masturbation.  There  was  little  irritability  about 
the  clitoris  or  other  external  organs,  the  patient  herself  be- 
ing inclined  to  recognize  a  deeper  and  inner  origin  for  her 
suffering.  The  morbid  desires,  and  the  disgusting  propen- 
sity thence  arising,  ceased  together  with  the  dysmenorrhceal 
pain,  upon  freely  incising  the  cervix  uteri,  and  dilating  its 


212  REFLEX   INSANITY 

canal.  They  have  not  since  returned,  save  in  one  singl? 
instance,  when  an  acute  attack  of  the  erotic  desire,  plainly* 
resulting  from  indulgence  in  so-called  pepper  tea,  was  at 
once  allayed  by  the  application  of  potassa  fusa  to  the  cervix. 
Now,  were  not  this  treatment  based,  as  it  is,  upon  a  broad 
and  general  physiological  principle,  its  effect  as  a  defence,  in 
similar  cases,  to  female  chastity,  threatened  and  undermined 
by  sources  of  irritation  within  the  patient  herself,  would  be 
sufficient  to  entitle  it  to  our  respectful  consideration.  The 
above  case  must  not  be  thought  more  pertinent  than  others 
of  a  similar  reflex  character,  where,  however,  there  is  no 
erotic  desire  or  other  direct  symptom  of  genital  irritation. 
However  masked,  they  all  instance  a  single  law. 

'*  It  would  be  difficult  to  state  precisely  to  what  extent  ap- 
propriate medical  and  surgical  treatment  can  be  effectual  in 
the  cure  of  female  insanity,  the  subject  as  presented  in  this 
light  being  comparatively  new  to  the  profession.  There  can 
be  little  doubt,  however,  that  in  so  far  as  the  mental  disturb- 
ance retains  its  original  reflex  character,  and  has  not  merged 
into  organic  cerebral  change,  which,  as  I  have  said,  is  com- 
paratively rare  in  women,  to  this  extent  and  so  long  should 
we  have  a  reasonable  hope  of  success,  nearly  as  great,  per- 
haps, as  in  relieving  the  other  reflex  disturbances  to  which 
the  female  is  confessedly  so  prone. 

"  As  regards  the  second  question  I  have  broached,  Is  such 
treatment  effected,  or  even  attempted,  in  insane  hospitals? 
the  answer  is  patent.  As  hospitals  are  at  present  organized, 
the  proper  treatment  cannot  be  afforded  insane  women,  for 
sufficient  reason. 

'"To  the  general  organization  of  our  public  asylums,  or 
to  its  details,  so  far  as  they  go,  I  would  take  no  exception. 
My  complaint  is,  that  their  most  excellent  organizations  do 
not  go  quite  far  enough  to  cover  the  important  class  of  cases 
we  are  now  considering.  They  stop  just  one  step  short  of 
the  mark.  I  am  here  speaking  from  personal  observation 
of  the  working,  theoretical  and  practical,  of  many  asylums, 
among  the  best  in  this  country  —  and  there  are  in  the  world 
none  in  advance  of  the  American  hospitals  for  the  insane; 


IN    WOMEN.  213 

SO  that  in  my  remarks  upon  this  subject  I  speak  with  perfecf 
confidence. 

"  The  reason  that  mental  disease  in  the  female,  dependent 
upon  reflex  uterine  or  ovarian  irritation,  is  not  generally 
treated  at  hospitals  for  the  insane  in  the  same  manner,  or  as 
successfully,  barring  only  the  lessened  risk  of  homicide  or 
of  suicide  before  cure,  as  in  private  practice,  is  in  the  main 
the  following :  — 

"  The  whole  and  sole  charge  of  the  patients,  medical, 
moral,  and  economical,  is  thrown  entirely  upon  the  superin- 
tendent of  the  hospital.  This  is  certainly  an  advantage  in 
everything  concerning  the  government  of  the  establishment, 
for  it  prevents  all  clash  of  opinion,  all  evasions  of  duty.  It 
is  excellent  in  every  respect,  save  alone  as  concerns  the 
weight  and  the  extent  of  medical  responsibility.  I  would  by 
no  means  lessen  the  superintendent's  authority,  but,  as  will 
be  seen,  would  free  him  from  his  present  involuntary  em- 
barrassment. 

''  The  superintendent,  as  at  present  situated,  cannot  make 
such  examination  of  a  female  patient,  or  pursue  such  methods 
of  treatment,  as  are  absolutely  required  for  the  relief  of  many 
forms  of  gynaecological  disease,  upon  the  existence  of  which, 
as  I  have  said,  her  mental  malady  not  unfrequently  depends. 
He  is  absolutely  prevented  from  this  alike  by  regard  for  the 
patient's  welfare,  for  his  own  personal  reputation,  and  for 
that  of  his  hospital.  So  constantly  compelled  to  see  the  pa- 
tient, he  appreciates  the  importance,  as  regards  other  details 
of  treatinent,  moral,  etc.,  that  he  should  retain  her  confi- 
dence and  escape  her  fears ;  he  recognizes  the  danger  lest 
an  endeavor  to  arrive  at  a  proper  diagnosis  of  her  disease 
should  seem  to  the  disordered  mind  only  an  attempt  at  im- 
proper and  unpardonable  liberties  with  her  person,  and 
should  she  ever  entirely  recover  her  reason,  be  so  represent- 
ed to  friends  and  to  the  community  by  her  perverted  and 
imperfect  memory.  These  risks,  so  great  in  sane  patients 
under  temporary  aberration  from  anaesthesia,  have  been  real- 
ized to  the  full  by  Dr.  Beale,  of  Philadelphia,  and  others; 
with  the  insane  they  are  increased. 


214  REFLEX    INSANITY 

"  In  this  strait,  upon  whom  is  the  superintendent  to  rely? 
Not  upon  his  assistants,  surely  —  younger  men,  and  often 
merely  pupils,  at  any  rate  placed  in  the  same  relations  as 
himself  to  the  patient,  the  hospital,  and  the  outside  world. 
Here  is  the  strange  and  paradoxical  example  of  a  physician 
pledged  by  even  higher  than  ordinary  motives  to  the  relief 
of  his  suffering  patients,  concerning  a  large  proportion  of 
whoni,  however,  his  hands  and  his  judgment  are  practically 
and  entirely  fettered.  He  cannot  search  for  the  manifesta- 
tions of  disease,  nor,  were  they  known  to  be  present,  can  he 
relieve  them ;  and  yet  we  all  contend,  and  strive  to  persuade 
the  community,  that  our  hospitals  for  the  insane  are  no 
longer  prisons;  that  they  are  not  houses  for  detention,  but 
for  cure.  The  existence  of  these  facts,  and  the  justness  of 
the  above  reasoning,  superintendents  have  repeatedly  ac- 
knowledged to  me  with  regret,  and  a  hope  that  the  evil  may 
be  remedied. 

"A  change  is  necessary:  how  can  it  be  accomplished? 
By  appointing  to  every  asylum  in  the  land  a  board  of  con- 
sulting physicians  —  useful  in  ordinary  cases  of  insanity, 
but  absolutely  indispensable  in  the  instance  of  insane  wo- 
men. These  gentlemen  should  be  selected  from  practition- 
ers in  the  immediate  neighborhood  of  each  asylum,  due  re- 
gard, of  course,  being  had  to  their  character  and  to  their 
professional  fitness.  The  position  should  be  an  honorary 
one,  and,  like  that  at  general  hospitals,  unattended  by  pecu- 
niary emolument;  and  the  superintendent  should  be  left  en- 
tirely to  use  his  own  discretion  as  to  calling  or  not  upon  the 
members  of  his  board  for  advice,  just  as  is  allowed  to  attend- 
ing physicians  or  surgeons  at  general  hospitals,  the  inten- 
tion being  to  render  consultations  and  a  division  of  medical 
responsibility  possible,  not  compulsorj'.  Strange  as  it  may 
seem,  there  appears  to  exist  but  a  single  asylum  in  this 
country  to  which  there  is  appended  a  board  of  medical  con- 
sultation. I  refer  to  that  most  admirable  establishment,  the 
Butler  Hospital,  at  Providence.  So  far  as  I  have  been  able 
to  ascertain,  —  and  I  have  been  aided  by  those  most  excel- 
lent authorities  in  all  matters  pertaining  to  the  insane,  Drs. 


IN    WOMEN.  215 

Raj,  of  Rhode  Island,  and  Edward  Jarvis,  of  Massachusetts, 
—  in  no  instance,  save  the  one  referred  to,  have  boards  of 
medical  advice  been  included  amongtheir  officers  and  means 
of  management  at  our  insane  hospitals. 

"  The  Connecticut  Retreat  has  a  Board  of  Medical  Visit- 
ors, whose  position  is  an  anomalous  one  :  as  much  super- 
visors of  general  administration,  apparently,  as  advisory  in 
the  treatment  of  patients,  they  are,  perhaps,  in  reality,  more 
strictly  honorary  than  either. 

"  There  was  formerly  an  Advisory  Board  attached  to  the 
City  Lunatic  Hospital  of  New  York,  at  Blackwell's  Island, 
discontinued  for  no  known  reason. 

"The  New  York  Hospital  has  Consulting  Surgeons  and 
Consulting  Physicians;  but  they  appear  to  have  nothing  to 
do  with  the  Bloomingdale  Asylum,  although  it  is  under  the 
same  general  authority  as  the  hospital.  The  case  is  similar 
to  that  of  the  McLean  Asylum,  which,  though  under  the 
same  trustees,  is  yet  separate  from  the  Massachusetts  Gen- 
eral Hospital.  The  last  has  Consulting  Physicians  and  Sur- 
geons, but  they  have  nothing  to  do  with  the  insane  depart- 
ment. They  may,  it  is  true,  have  been  occasionally  consulted 
by  Dr.  Bell,  and  possibly  by  his  successors,  in  cases  of  doubt^ 
ful  sickness  of  a  general  character,  just  as  other  gentlemen, 
from  time  to  time,  have  been  called  upon  to  give  opinion. 
As  matters  now  remain,  such  consultations  are  wholly  un- 
official, and  Dr.  Ray's  establishment,  therefore,  would  seem 
at  present  to  stand  alone,  and  to  furnish,  with  its  skilful  ad- 
visory staff  of  Drs.  Mauran  and  Miller,  an  example  to  be 
followed. 

"  So  far  these  remarks  have  been  based  upon  my  own  per- 
sonal observation  of  the  needs  and  advantages  of  the  meas- 
ure I  have  proposed.  I  am  able  to  go  farther  than  this, 
however,  and  to  give  corroborative  evidence  from  superin- 
tendents themselves. 

"  In  a  report  recently  rendered  to  the  Legislature  of 
Massachusetts,  the  views  of  the  writer  as  oi^e  of  the  State 
Commissioners  in  Insanity  were  embodied,  he  fully  recog- 
nizing, however,  and  admitting  the  fact  that  the  appointmenl 


2l6  REFLEX    INSANITY 

of  boards  of  medical  consultation,  as  a  part  of  the  internal 
management  of  hospitals,  should  devolve  upon  their  boards 
of  trustees,  and  in  no  way  be  controlled  by  the  State.  The 
various  opinions  and  recommendations  presented  in  the  re- 
port alluded  to  were  very  properly  submitted  to  the  Super- 
intendents of  the  several  State  asylums  by  the  Legislative 
Committee  to  which  it  had  been  referred,  and  almost  without 
exception  they  were  cordially  indorsed.  With  respect  to 
the  propriety  of  appointing  consulting  physicians  to  the 
hospitals  there  was  not  a  dissenting  voice;  Drs.  Tyler,  of 
the  McLean  Asylum,  Walker,  of  that  at  South  Boston,  and 
Choate,  of  the  Taunton  Hospital,  acknowledging  that  they 
had  each  felt  the  need  of  such  assistance,  and  would  gladly 
avail  themselves  of  it  were  it  afforded  them,  while  Dr.  Ray, 
of  Providence,  who  alone  could  speak  from  personal  experi- 
ence of  its  advantages,  gave  the  Committee  to  understand 
that  he  considered  his  Board  as  at  once  comfort,  relief,  and 
safeguard.  Such  would  probably  be  found  to  be  the  unani- 
mous opinion  of  gentlemen  engaged  in  this  most  responsible 
specialty. 

"  I  have  now  presented  the  subject  only  in  its  relations  to 
patient  and  superintendent,  and  have  endeavored  to  show 
the  advantages  and  necessity,  alike  to  both,  of  the  measure 
proposed.  I  might  well  cease  here,  confident  that  my  re- 
marks have  been  sufficiently  conclusive.  The  subject  is  no 
less  important,  however,  to  the  community  at  large,  in  its 
relations  to  gynaecological  practice  and  obstetric  juris- 
prudence. 

'*  Gynaecological  practice,  as  I  have  already  hinted,  covers 
legitimately  the  greater  number  of  cases  of  female  insanity, 
but  it  is  to  hospitals  for  the  insane  that  the  profession  must 
necessarily  send  many  of  these  patients,  and  it  is  to  hos- 
pitals for  the  insane  that  we  must  therefore  look  for  the  most 
effectual  trial  of  rational  methods  of  treatment,  and  from 
them  trust  for  examples  of  successful  cure.  For  this  success 
they  have  already,  with  the  single  exception  alluded  to, 
every  possible  adjunct:  seclusion  of  their  patients  from  ex- 
citing causes ;  their  absolute  control  as  to  diet,  habits,  and 


IN    WOMEN.  217 

whole  detail  of  life;  the  possibility,  so  far  as  skilled  attend- 
ance is  concerned,  of  carrying  out  any  desired  plan  of  treat- 
ment. Were  such  indorsed  by  men  experienced  in  similar 
methods  as  applied  in  every-day  practice,  the  superintendent's 
responsibilities,  doubts,  and  risks  would  all  be  lightened, 
and  the  measures  indicated  be  readily  enough  pursued. 
Before  long  there  would  be  a  mass  of  digested  observations 
and  medical  reports  issuing  from  these  very  hospitals, 
wliich  would  be  of  immense  value  to  the  profession  in  civil 
life. 

"  I  have  referred,  and  I  trust  it  will  not  be  thought  with 
disrespect,  to  the  tendencies  at  asylums,  in  the  search  for 
cerebral  lesion,  to  ignore  all  others.  I  could  relate  many 
instances  corroborative  of  this  fact,  but  it  is  unnecessary. 
The  very  nature  of  mental  disturbance  would  of  itself  be 
sufficient  to  explain  it,  did  we  not  have  additional  reason  in 
the  position  in  which  I  have  shown  hospital  officers  to  stand 
in  relation  to  their  cases  of  insane  women.  It  is  evident 
in  the  very  details  of  asylum  autopsies  as  compared  with 
those  at  general  hospitals,  in  the  statements  of  appearances 
found,  and  in  the  silence  upon  points  not  supposed  essential. 
I  would  not  imply  that  there  are  not  most  faithful  and 
thorough  pathologists  among  psychologists —  a  combination, 
of  which  Dr.  Workman,  of  Toronto,  is  by  far  the  most  ex- 
cellent example  with  whom  I  am  personally  acquainted  ;  nor 
do  I  believe  there  are  many  superintendents  in  this  country 
who  sympathize  with  their  other  Canadian  representative, 
Dr.  Douglass,  of  the  Lower  Province,  whose  assertion  to 
me  of  contemptuous  disbelief  in  the  need  or  advantage  of 
autopsies  of  the  insane,  was  only  additional  proof,  had  such 
been  needed,  that  his  Government  Asylum  at  Beaufort,  near 
Quebec,  however  fair  in  outside  seeming,  is  based  on  an 
erroneous  view  of  management;  that  it  is  conducted  for 
private  rather  than  for  public  good,  and,  by  comparison 
with  that  of  Canada  West,  that  it  should  be  abated  as  an 
error  and  a  nuisance  by  Parliament.*     This  is  no  digression. 

*  This  was  in  1864.     I  am  informed  (1870)  that  the  suggestion  above  maia 
was  effectual  in  producing  the  necessary  change. 


2l8  REFLEX    INSANITY 

The  topic,  both  personal  and  theoretical,  is  one  intimately 
related  to  that  we  have  been  considering,  and  I  shall  discuss 
it  more  fully  upon  another  occasion.  "When  autopsies  of 
insane  females  shall  have  become  more  frequent  and  moic 
carefully  studied,  the  importance  of  the  doctrines  now  urged 
will  become  the  more  apparent. 

"I  have  intimated  that  the  appointment  of  medical  ad- 
visers to  insane  hospitals  would  be  of  advantage  to  obstetric 
jurisprudence. 

"  We  are  all  familiar  with  those  difficult  cases  of  supposed 
or  alleged  insanity  in  females  that  from  time  to  time  make 
their  appearance  in  our  courts  of  justice,  on  writs  of  habeas 
corpus  or  otherwise,  from  asylums,  puzzling  counsel,  medi- 
cal experts,  and  judge.  Such  cases  are  common  enough  in 
private  practice,  and  are  found  generally  amenable  to  treat- 
ment. There  is  no  reason  that  they  should  still  be  allowed 
to  serve  as  excitants  of  public  scandal,  or  to  bring  discredit 
upon  hospital  management,  or  to  subject  their  officers  to 
suspicion  as  venal. 

"  There  is  a  vast  field  above  and  beyond  all  this,  which 
many  writers  have  approached,  none  more  boldly  than  lately 
Dr.  Ray*  —  important  beyond  all  estimate  in  its  jurispru- 
dential relations,  but  which  has  hardly  as  yet  been  entered, 
certainly  not  to  any  extent,  from  the  quarter  in  which  we  are 
now  standing.  I  refer  to  the  legal  and  moral  responsibili- 
ties of  women,  whether  maniacal  or  but  partially  aftected ;  a 
matter  of  infinite  interest,  of  ipfinite  practical  importance,  I 
can  now  but  allude  to  it.  It  is  another  proof  to  us  of  what 
may  be  the  results,  scientific  and  effective,  from  insane 
asylums  when  they  shall  have  been  made  what  they  may 
more  fully  become,  hospitals  for  research,  for  ratio'nal  ex- 
periment, and  for  cure. 

"  In  accordance  with  the  arguments  now  submitted,  I 
would  offer  the  following  resolutions,  which  I  trust  the 
Association  may  unanimously  see  reason,  in  its  wisdom,  to 
adopt  and  to  render  effective  :  — 

•  Treatise  on  Mental  Hygiene ;  Report  of  Butler  Hospital  for  1864. 


IN   WOMEN.  219 

"  Resolved,  That  in  the  opinion  of  the  American  Medical 
Association  it  is  expedient  that  there  should  be  attached  to 
every  public  hospital  for  the  insane,  one  or  more  consulting 
physicians,  who  may  be  consulted  at  the  discretion  of  the 
superintendent;  such  measure  being  alike  for  the  interest 
of  the  hospital,  its  medical  officers,  and  its  patients. 

^'^ Resolved,  That  a  copy  of  the  above  resolution  be  trans- 
mitted to  the  Board  of  Trustees  of  each  of  our  public  hos- 
pitals for  the  insane ;  and  also  to  the  Secretary  of  the 
Association  of  American  Superintendents,  with  the  request 
that  it  may  be  indorsed  by  that  body,  and  the  action  pro- 
posed be  urged  upon  the  respective  boards  with  which  its 
members  are  officially  connected."* 

I  have  thus,  very  imperfectly  as  I  am  aware,  pre- 
sented a  portion  of  my  views  as  to  the  causation  and 
treatment  of  a  large  proportion  of  the  cases  of  insan- 
ity occurring  in  women.  I  have  furnished  evidence, 
in  confirmation  of  these  views,  from  many  of  the 
leading  psychological  experts  of  the  present  day.  I 
have  shown  that  my  deductions  are  such  as  a  priori 
ought  to  have  resulted,  and  such  as  alone  can  explain 
admitted  facts.  I  have  proved  that  these  views  are 
not  generally  entertained  by  the  specialty  devoted  to 
the  insane,  or  if  entertained,  are  not  generally  acted 
upon  in  practice.  I  have  confined  myself  in  the  main 
to  the  general  question  of  causation,  for  the  present 
omitting  the  discussion  of  minor  but  scarcely  less 
important  questions  and  details  ;  upon  all  of  which  I 
have  now  a  mass  of  evidence,  that  I  shall  hereafter 

*  The  above  paper  having  been  read  before  the  Section  on  Obstetrics,  and 
warmly  approved  by  many  of  its  members,  the  resolutions  appended  were  re« 
ferred  to  the  Association  at  large,  and  were  indorsed  by  a  unanimous  vote. 


220  REFLEX   INSANITY 

most  gladly  adduce.  I  have  refrained,  save  in  what 
pertains  to  pregnancy,  from  using  the  testimony  of 
gynaecologists,  and  of  the  profession  at  large,  strongly 
corroborative  as  this  would  have  been  of  my  every 
position,  preferring  to  meet  the  objections  that  have 
been  made,  by  answers  from  a  similar  source.  I  have 
attempted  to  avoid  all  resort,  or  appearance  of  resort, 
to  any  special  pleading,  though  such  is  apparent 
enough  in  these  objections  ;  that,  for  instance,  a  gynas- 
cologist  must  necessarily  be  a  practitioner  of  but  one 
idea,  and  therefore  incompetent  —  the  truth  being, 
that  without  at  least  one  fundamental  idea,  no  man 
should  be  deemed  fit  for  the  charge  of  any  sick  wo- 
men, whether  insane  or  in  their  right  mind. 

I  have  endeavored  to  deal  fairly  with  gentlemen 
whose  opinions,  from  a  previous  bias  of  perhaps 
many  years'  standing,  may  clash  with  my  own,  and 
have  acknowledged  my  belief  that,  in  most  of  the 
quarters  of  this  important  sphere,  they  have  left  little 
unaccomplished  that  was  practicable  for  the  good  of 
their  patients.  I  have  striven  sedulously  to  avoid  ex- 
pressions or  a  tone  that  could  possibly  create  undue 
offence  —  though  not,  I  conceive,  upon  all  occasions, 
myself  treated  as  fairly.  With  reference  to  certain 
of  the  arguments  with  which  I  have  been  met,  I 
might  well  have  said,  as  did  Blundell  in  answering 
the  current  criticisms  upon  ovariotomy,  for  our  cases 
are  in  many  respects  very  parallel :    "  These  men  are 


IN    WOMEN.  221 

butting  their  heads  against  a  stone  wall ;  and  the 
grimaces  they  make,  on  feeling  the  solidity  of  the 
materials,  are  as  amusing  as  they  are  pitiable."  Had 
I  not,  at  this  time  at  least,  decided  to  fortify  my  plea 
by  evidence  that  had  been  afforded  solely  by  psychol- 
ogists, I  might  have  adduced  more  trenchant  com- 
mentaries than  I  have  done,  even  indeed  from  the  au- 
thorities I  have  made  use  of. 

But,  on  the  other  hand,  it  is  a  good  rule  in  medi- 
cine that  where  there  is  a  choice  of  measures,  the 
harshest  is  always  to  be  chosen  the  last.  It  is  as  true 
of  the  birth  of  a  principle  or  of  a  method  of  practice, 
as  of  a  child.  In  surgery,  no  incision  is  to  be  made 
longer  or  deeper  than  the  occasion  requires.  Sin- 
cerely believing,  as  I  do,  that  the  only  rational  treat- 
ment of  insane  women  must  be  based  upon  the  same 
general  medical  and  surgical  principles  as  those  that 
control  the  management  of  every  other  conceivable 
form  of  disease,  I  could  say  no  less  than  I  have  done. 
To  the  profession  I  leave  the  decision  of  the  questions 
involved. 

A  few  days  subsequently  to  the  meeting  of  the  As- 
sociation at  which  the  above  report  was  presented,  I 
attended,  as  its  delegate,  the  Annual  Meeting  at  Pitts- 
burg of  the  Association  of  American  Superintendents, 
with  instructions  to  urge  upon  these  gentlemen  the 
propriety,  for  the  purposes  of  science  and  of  effectual 
practice,  of  a  more  intimate  union  upon  their  part 


223  REFI-EX   INSANITY 

with  our  own  body,  representing  as  this  does  the  pro* 
fession  at  large.  The  cordiality  with  which  I  was 
received  by  the  large  circle  of  Superintendents  then 
present,  the  majority  of  them  till  then  strangers  to 
me,  and  the  respectful  attention  with  which  my  views, 
so  far  as  I  presented  them,  were  met,  have  but  served 
to  confirm  me  in  the  opinion  that  those  who  have  so 
ungraciously  endeavored  to  stifle  this  discussion  do 
not  represent  the  main  body  of  American  psycholo- 
gists, and  that  the  seeds  of  a  more  rational  practice, 
now  to  be  scattered  by  the  aid  of  the  press,  will  not 
fall  upon  wholly  unfruitful  soil. 

The  following  is  the  report  which  was  rendered  to 
the  American  Medical  Association  at  its  meeting  the 
ensuing  year,  1866. 

"At  the  last  meeting  of  this  Association  the  undersigned 
was  appointed  its  delegate  to  the  Association  of  Medical 
Superintendents  of  American  Institutions  for  the  Insane, 
for  the  purpose  of  urging  upon  that  body  the  advantages 
of  a  more  intimate  union  with  your  own,  alike  for  the  pur- 
poses of  science  and  effectual  practice.  Having  attended  to 
the  duty  confided  to  him,  he  would  render  the  following 
report :  — 

"  Four  days  after  your  own  adjournment,  3'our  delegate 
met  the  associated  superintendents  at  Pittsburg,  Pa.,  and 
communicated  to  them  your  expressed  desire,  urging,  at  the 
same  time,  the  mutual  advantage  that  would  ensue  to  both 
parties  interested,  themselves  and  yourselves,  from  the  ac- 
tion proposed.  He  was  very  courteously  received  and  hos- 
pitably entertained  by  the  Association  of  Superintendents, 
and  your  request  was  listened  to  with  the  respect  that  its 
importance  demanded,  many  gentlemen  seeming  alive  to 
the  necessity  that  the  proposed  union  should  be  effected. 


IN    WOMEN.  223 

When,  however,  the  question  was  taken,  your  proposal  was 
not  acceded  to,  and  a  different  time  and  place  than  your 
own  were  fixed  for  the  meeting  of  the  superintendents  the 
present  year. 

"By  his  action  in  the  premises,  your  delegate  might  seem 
relieved  from  further  remark.  Having  discussed  this  mat- 
ter, however,  as  he  has  done,  with  the  gentlemen  comprising 
the  offstanding  association,  and  become  familiar  with  their 
temper  and  opinions  upon  this  very  important  subject,  he 
would  have  but  half  fulfilled  his  duty  did  he  refrain  from 
expressing  his  views  concerning  the  present  position.  He 
does  this  the  more  cheerfully,  from  the  fact  that  the  recent 
meeting  of  the  superintendents  at  Washington,  though  not 
held  in  accordance  with  your  desire,  has  permitted  a  larger 
number  of  superintendents  than  usual  to  attend  your  own 
convocation;  and  though,  by  their  action,  it  has  been  ren- 
dered impossible  for  you  to  send  a  delegate  to  their  meeting 
of  the  present  year,  as  you  decided  by  vote  to  continue  to  do 
until  the  proposed  union  shall  have  been  effected,  the  oppor- 
tunity has  been  afforded  for  j'ou  to  reiterate  your  opinion, 
not  through  a  delegate  merely,  but  in  your  own  persons,  as 
now  assembled. 

"  The  views  referred  to  naturally  subdivide  themselves 
according  as  they  relate —  ist,  to  the  welfare  of  this  Associ- 
ation; 2dly,  to  that  of  the  profession  at  large;  3dly,  to  that 
of  the  great  class  of  sick  persons  more  directly  interested  in 
your  action,  namely,  the  insane;  4thly,  to  that  of  the  com- 
munity; and  it  might  be  added,  5thly,  to  that  of  the  super- 
intendents of  asylums  themselves. 

"  I.  Of  what  advantage  is  it  to  this  Association  that  it 
represent,  in  reality,  the  profession  of  the  country.?  It 
would,  at  first  sight,  seem  that  this  question  could  hardly 
have  been  soberly  asked,  its  answer  is  so  very  evident;  and 
yet,  practically,  its  discussion  at  the  present  moment  and  in 
the  present  connection  is  well  worthy  your  attention.  In 
this  brief  report,  however,  there  can  be  offered  but  a  very 
few  words. 

"  That  a  house  divided  against  itself  cannot  stand,  is  as 


224  REFLEX    INSANITY 

true  in  your  affairs  as  in  those  of  other  men.  The  position 
of  the  Association  of  Superintendents  towards  your  own 
organization  is  unlike  that  of  the  ordinary  medical  bodies 
represented  in  your  councils  by  delegates.  It  is  itself  a 
great  centralizing  power,  effectual,  to  a  certain  extent,  no 
doubt,  for  good;  effectual  also  for  harm.  Its  conferences 
have  been  the  means  of  eliciting  an  immense  deal  of  im- 
portant information  concerning  the  hygienic  management 
and  economic  detail  of  asylums ;  which  could,  however,  with 
equal,  and  indeed  greater,  advantage  have  been  presented 
through  your  own  channel.  On  the  other  hand,  these  com- 
munications have  not  been  presented  directly  to  the  profes- 
sion ;  few  of  whom,  indeed,  do  they  reach  at  all.  The  Asso- 
ciation of  Superintendents  and  its  official  publication  —  the 
one  composed  of,  and  the  other  conducted  by,  however  com- 
petent men  —  constitute,  in  reality,  a  partition  wall  between 
the  very  important  department  of  the  profession  they  repre- 
sent and  your  own  great  body  of  workers,  the  profession  at 
large. 

"In  all  specialties  —  and  the  care  of  the  insane  is  but 
such  —  the  practitioner  has  little  reason  to  separate  himself 
from  his  fellows.  He  is  incompetent  for  his  work  unless  he 
has  himself  been  tried  in  the  furnace  of  general  practice; 
he  is  unfit  for  it  if  he  is  unwilling  to  freely  communicate 
with  the  mass  of  his  profession.  Researches  merely  for  the 
benefit  of  a  limited  circle,  publications  merely  for  a  few  se- 
lected readers,  alike  fail  of  the  two  great  ends  that  alone 
should  be  sought  by  the  true  physician  —  the  general  edifi- 
cation of  his  professional  brethren,  and  the  general  relief 
of  those  sick  persons  whom  he  professes  to  wish  to  cure. 

"Viewed  in  this  light,  the  profession  and  this  Association, 
its  representative,  have  a  right  to  claim,  from  every  one  of 
its  members,  individual  and  combined  efforts  for  the  general 
good ;  and,  looking  upon  separate  and  close  organizations 
with  a  certain  measure  of  very  natural  distrust,  it  is  clearly 
your  duty  to  use  such  measures  as  may  afford  themselves  to 
claim  for  this  body  a  more  hearty  allegiance. 

"  However  decided  one's  sympathy  with  efforts  to  advance 


IN  WOMEN.  225 

all  legitimate  specialties,  still  the  good  of  the  general  prac* 
titioner  must  rise  superior  to  all  other  considerations.  Fol 
this  reason,  every  attempt  to  directly  separate  any  class  of 
specialists  from  the  mass  of  their  fellows  is  to  be  deprecated. 
The  ophthalmologists  of  this  country,  for  instance,  who 
comprise  among  their  number  some  of  your  most  worthy 
brethren,  are  doing  much  for  the  glory  of  medicine;  yet  it 
is  to  be  lamented  that  they  should  desire,  by  organizing 
themselves  into  a  separate  Association,  practically  to  disso- 
ciate their  department  from  its  legitimate  and  influential 
connection  with  the  parent  body,  as  one  of  its  chief  and 
strongest  supports. 

"Through  your  so-called  Sections,  wisely  and,  if  thought 
necessary,  permanently  organized,  all  the  work  of  special 
organizations  can  be  effected  as  thoroughly  as  by  any  other 
method,  and  with  infinitely  more  advantage  to  the  mass  of 
the  profession. 

"  2.  Whatever  redounds  to  the  advantage  of  this  Associa- 
tion, either  as  regards  the  respect  and  honor  in  which  it  is 
held  or  the  influence  it  is  enabled  to  exert,  is  necessarily  also 
to  the  advantage  of  its  individual  members,  and  the  institu- 
tions, whether  hospitals,  societies,  or  schools,  that  they  rep- 
resent. This  body  should  be  considered,  as  was  the  aim  of 
its  founders,  the  exponent  of  American  medical  position  and 
scientific  acquirement.  That  the  possibility  of  this  actually 
taking  place  has  been  in  some  quarters  inconsiderately  made 
light  of,  is  neither  proof  nor  argument  that  it  cannot  be 
eftected.  Selection  you  have  from  all  worth  the  culling.  It 
only  requires  a  wise  combination  of  forces  to  render  these, 
your  forces,  eftective  powers  —  efl'ective  to  raise  the  standard 
of  medical  education,  practice,  and  result.  You  cannot 
afford  to  allow  any  of  your  main  departments  to  attempt  an 
independent  crusade.  In  union  alone  is  there  the  com- 
pletest  strength,  and  the  strength  of  the  whole  is  in  reality 
the  strength  of  each  individual  of  your  numbers  from  the 
profession  at  large. 

"  3.  There  can  be  no  doubt  as  to  the  advantage  to  the 
great  class  of  the  insane,  of  a  more  direct  and  personal  in- 

15 


226  REFLEX   INSANITY 

terest  in  their  welfare  on  the  part  of  physicians  generally, 
than  now  obtains.  Were  it  absolutely  certain  that  there 
could  be  no  possible  advance  in  the  knowledge  anci  treat- 
ment of  insanity,  the  case  might  be  difterent;  but  the  expe- 
rience of  the  past  with  all  its  great  changes,  most  of  them 
reforms,  teaches  otherwise.  That  our  asylums  are  so  excel- 
lently managed,  officered  by  such  competent  superintendents, 
and  fruitful  to  the  extent  they  are  of  improvement  in  their 
patients,  affords  undoubted  cause  for  laudation ;  but  this  is 
a  very  different  thing  from  being  perfect.  The  mere  fact 
that  so  large  a  proportion  of  insane  patients  has  thus  far 
proved  incurable  is  surely  a  reason  for  bending  to  the  sub- 
ject the  scrutiny  of  a  larger  and  larger  number  of  skilled 
investigators,  and  so  perhaps  eventually  working  for  the  in- 
sane of  the  present  day  as  great  a  revolution  in  respect  to 
improvement  as  was  efl[iected  by  Pinel  for  those  of  the  past. 
As  one  most  efficient  agent  towards  such  increased  interest 
in  the  study  of  insanity  would  be  found  a  closer  union  of 
superintendents  with  your  own  Association. 

"4.  To  the  community  there  would  be  gains,  over  and 
above  these  already  enumerated,  were  the  Association  reiin- 
forced  by  those  gentlemen  who  have  practically  seceded 
from  its  ranks.  There  exists  still  too  prevalently  the  feeling 
that  asylums  for  the  insane  are  in  reality  but  prisons,  under 
a  less  repulsive  nam.e.  It  is  needless  to  deny  the  fact  Ev- 
ery physician  is  aware  of  the  impression  to  which  reference 
is  now  made,  and  of  the  check  it  exerts  in  many  unhappy 
instances  upon  the  needed  transferrence  of  a  patient  to  a 
more  suitable  and  healthful  mental  atmosphere. 

"Now  asylums  should  be  stripped  of  this  odium  still 
clinging  to  them,  for  which  there  was  formerly  but  too  good 
reason.  They  should  be  made  and  should  be  shown  to  be, 
first  and  foremost,  not  houses  for  detention,  but  hospitals 
for  cure;  and  this  can  best  be  done  by  encouraging  a  more 
extensive  knowledge  of  insanity  in  all  its  phases  on  the  part 
of  the  general  practitioner.  Were  this  obtained,  prejudices 
would  be  softened  or  efTaced,  patients  would  often  be  earliei 
submitted  to  proper  treatment,  a  point  vital  for  their  chance 


IN   WOMEN.  227 

of  cure,  and  many  more  valuable  members  of  the  commu- 
nity saved  to  it,  to  their  families,  and  to  themselves. 

"5,  and  finally.  In  claiming  that  even  the  interests  of 
psychology  and  of  superintendents  would  be  benefited  by 
the  measure  you  instructed  your  delegate  to  urge,  no  more 
is  stated  than  the  facts  in  the  case  prove  to  be  true.  At 
Pittsburg  it  was  alleged,  privately  and  publicly,  by  more 
than  one  superintendent,  that  if  the  proposed  union  were 
eff"ected,  it  would  be  the  death-blow  to  their  own  Association. 
Such  a  result  is  not  the  object  that  yourselves  have  aimed  to 
effect.  Granting,  however,  that  it  should  occur,  would  the 
dissolution  referred  to  prove  in  reality  detrimental  to  the 
best  interests  of  medicine?  That  superintendents  should 
desire  to  cultivate  to  a  higher  degree  the  brotherly  feeling 
likely  to  exist  among  gentlemen  engaged  in  a  kindred  occu- 
pation, where  there  is  little  or  no  possibility  of  their  inter- 
fering with  each  other,  is  a  very  pleasant  thing.  Equally 
agreeable  is  it  for  one  of  their  number  each  year  to  be  able 
to  exhibit  his  own  establishment  to  his  fellows,  receive  the 
encomiums  certain  in  their  generous  rivalry  to  be  deserved, 
and  gain  for  himself  the  cumulative  experience  of  so  many 
kindly  critics.  But  on  the  other  hand,  in  medicine,  the 
good  of  the  greater  number  is  sure,  in  the  long  run,  to  claim 
its  own ;  and  here  in  your  midst  are  hungry  souls,  craving 
for  the  cases,  countless  almost  as  the  sands  on  the  sea- 
shore, of  partial,  incipient,  or  confirmed  insanity',  that  as 
yet  have  never  been  at  an  asylum,  or  have  been  discharged 
as  fit  to  remain  at  home,  or  incurable,  more  satisfying  food 
regarding  their  rational  causation,  their  treatment,  or  the 
prevention  of  the  disease.  These  hospital  superintendents 
have  been  set  apart  from  their  fellows,  in  part  at  least,  be- 
cause of  their  supposed  illuminating  power.  Freed  from 
the  present  self-imposed  bushel  of  their  own  Association, 
then  would  their  light  shine  so  as  to  brighten  the  whole 
professional  firmament. 

"The  officers  of  hospitals  are  compelled  to  rest,  for  a 
certain  measure  of  their  reputation,  their  influence,  their 
power,  upon  yourselves  outside ;  for  it  is  by  you  that  pa- 


228  REFLEX   INSANITY 

tients  are  advised  to  admission,  their  certificate  of  entrance 
signed,  and  the  therapeutic  judgment  and  conduct  of  those 
who  take  them  in  charge  indorsed,  in  case,  as  so  often  hap- 
pens, an  appeal  is  made  from  themselves  to  a  more  public 
tribunal.  It  is  jou,  moreover,  who  are  to  pronounce,  year 
after  year,  and  generation  after  generation,  whether  the 
same  advance  is  made  in  the  treatment  of  insanity  that  the 
divine  mistress,  whom  we  all  serve,  has  a  right  to  exact  from 
her  votaries.  No  branch  of  medicine  can  be  dissevered  from 
all  others  with  safety  to  itself.  Keeping  aloof  from  the  rest, 
it  is  easily  distanced,  and  becomes  eftete.  Or,  if  arrogantly 
claiming  for  itself  exclusive  rights,  it  by  that  act  challenges 
an  examination  into  the  grounds  of  its  assumption ;  if  these 
prove  lacking,  then  comes  for  it  inevitably  a  fall  from  its 
high  estate. 

*'  Pregnant  with  practical  and  practicable  idea,  as  is  every 
relation  of  your  profession  to  that  great  sickness,  Insanity, 
worse  than  mortal,  when  incurable,  there  is  one  other  point 
to  which,  in  this  connection,  your  delegate  deems  it  well  to 
draw  your  attention. 

"  It  is  well  known  that  of  all  the  cases  interesting  to  med- 
ical jurists  that  enter  our  civil  and  criminal  courts,  those  of 
insanity  are  the  most  perplexing.  From  the  general  initia- 
tory question,  In  what  does  insanity  consist?  down  to  the 
special  one  of  each  particular  occasion.  Was  or  is  this  person 
insane.?  there  is  often  exhibited  a  great  and  very  conflicting 
diversity  of  sentiment;  much  of  it  undoubtedly  necessary, 
because  inherent  in  the  questions  themselves,  and  much  of 
it  capable  of  being  removed.  There  is  an  equal  variance 
of  sentiment  as  to  who  shall,  and  who  shall  not  be  per- 
mitted to  express  his  opinion  as  an  expert,  and  who  shall  be 
entitled  to  credence.  There  exist,  upon  this  point,  wide  ex- 
tremes of  opinion.  Dr.  Ray,  for  instance,  in  his  "Medical 
Jurisprudence,"  and  the  able  editor  in  chief  of  the  American 
Journal  of  Insanity,  Dr.  Gray,  of  the  Utica  Asylum,  as  I 
have  elsewhere  shown,  would  confine  this  privilege  or  this 
ability  to  the  few  wise  men  who  happen  to  hold  positions  at 
the  head  of  an  asylum.     Sir  Benjamin  Brodie,  on  the  other 


IN    WOMEN.  229 

hand,  a  psychologist  of  no  mean  repute,  extends  it  even  to 
those  bejond  the  ranks  of  the  general  profession,  and  de- 
clares that  *  It  is  a  great  mistake  to  suppose  that  this  is  a 
question  which  can  be  determined  only  by  medical  prac- 
titioners. Any  one,'  he  says,  '  of  plain,  common  sense,  and 
having  a  fair  knowledge  of  human  nature,  who  will  give  it 
due  consideration,  is  competent  to  form  an  opinion  on  it; 
and  it  belongs  fully  as  much  to  those  whose  office  it  is  to 
administer  the  law,  as  it  does  to  the  medical  profession.'  * 

"A  similar  opinion  has  been  expressed  by  one  of  your 
own  body,  the  distinguished  American  editor  of  the  Cyclo- 
pedia of  Practical  Medicine,  the  late  Dr.  Dunglison,  of 
Philadelphia.  Says  this  gentleman,  '  In  regard  to  the  na- 
ture of  the  testimony  relied  upon  in  cases  of  insanity,  and 
the  mode  of  judging  of  the  same,  there  is  much  room  for 
animadversion.  Too  great  weight  appears  to  be  given  to 
medical  testimony  in  such  cases.  It  has  always  been  the 
expressed  conviction  of  the  writer,  that  medical  men  are  no 
better  judges  of  the  existence  of  mental  alienation  than  well- 
informed  and  discriminating  individuals  not  of  the  pro- 
fession. The  only  advantage,  at  least,  which  they  can  be 
presumed  to  have,  is  from  the  constant  habits  of  observation 
and  discrimination,  which  the  practical  exercise  of  their 
profession  requires.  Yet,  for  no  other  reason  than  that  they 
belong  to  the  medical  profession,  inferior  men,  whose  judg- 
ments on  any  other  subject  would  be  contemned,  are  often 
called  upon  to  decide  and  establish  the  existence  or  non- 
existence of  a  mental  condition  which  demands  the  most 
careful  and  rigid  scrutiny.' 

"The  same  difference  of  opinion,  shown  above  to  obtain 
among  medical  men,  exists  also  among  the  expounders 
of  the  law.  Thus  Wharton,  justly  celebrated  alike  for  his 
treatise  on  Medical  Jurisprudence  and  his  several  works 
upon  Criminal  Law,  states  that  '  No  juryman,  if  properly 
tender  of  his  conscience  and  of  public  opinion,  will  base  his 
verdict  upon  other  evidence  than  that  of  those  best  able,  from 

•  Mind  and  Matter  ;  or,  Physiological  Inquiries,  p.  105. 


230  REFLEX    INSANITY 

long  training  and  close  attention,  to  understand  the  features 
of  the  case.  In  some  cases  the  difference  between  a  scien- 
tific, or  technical  opinion,  and  that  of  a  layman,  is  not  so 
much  in  the  results  attained,  as  in  the  guarantee  afforded  by 
the  superior  attainments  and  more  minute  expertness  of  the 
man  of  science.  The  declaration  of  such  a  man  is  insured 
against  the  possibility  of  error  to  the  full  extent  of  the  pro- 
tection of  science  in  its  present  stage  of  development.  Pro 
foro,  this  degree  of  certainty  is  sufficient,  because  it  is  the 
highest  attainable ;  but  the  same  cannot  be  said  of  any 
other.'  * 

"  Carried  into  court,  however,  it  is  found  that  the  rulings 
upon  this  point  have  been  diametrically  opposed  to  each 
other.  In  New  York,  the  Court  of  Appeals  has  decided, 
though  with  a  strong  dissenting  sentiment,  that  none  but 
professional  witnesses  are  competent  to  testify  on  the  subject 
of  insanity  (Dewitt  v.  Barley  &  Schoonmaker,  5  Selden, 
371),  while  the  Supreme  Court  of  the  same  State  admits  the 
opinions  of  laymen  (Culver  v.  Haslem,  7  Barb.,  3i4).  In 
Pennsylvania  the  point  has  been  settled  in  favor  of  admitting 
the  testimony  of  non-professional  witnesses  (Rambler  v. 
Tryan,  7  Serg.  &  Rawle,  90;  Wogan  v.  Small,  11  Serg.  & 
Rawle,  141).  In  Connecticut,  decisions  have  been  of  a  simi- 
lar character  (Grant  r.  Thompson,  4  Conn.,  203).  In  Indi- 
ana, provided  the  facts  are  stated  upon  which  his  opinions 
are  founded,  an  unprofessional  witness  may  express  his 
opinion  regarding  the  existence  of  insanity  (Doe  v.  Reagan, 
5  Black.,  217).  The  same  is  true  in  Tennessee,  North  Caro- 
lina, and  Ohio  (Gibson  v.  Gibson,  9  Yerger,  329;  Clary  v. 
Clary,  2  Iredell's  Law  Rep.,  78;  The  State  v.  Clark,  12 
Ohio,  483) ;  and  in  Vermont  also  (Lester  v.  Pittsford,  7 
Verm.,  158;  Morse  v.  Crawford,  19  Id.,  499). 

"In  view  of  these  facts,  either  of  the  above-mentioned 
extreme  decisions  being  disadvantageous  to  the  mass  of 
your  profession,  as  refusing  to  you,  on  the  one  hand,  com- 
petence to  express  any  opinion  in  cases  which  you  maj 

•  Medical  Jurisprudence,  §  91. 


IN   WOMEN.  231 

perhaps  have  watched  closely  for  years,  and  extending,  on 
the  other,  equal  rights  and  privileges  with  yourselves,  in 
purely  professional  matters,  to  the  most  unprofessional  per- 
sons, it  is  not  improper  to  urge  upon  you  action,  which,  if 
taken,  will  also  serve  to  render  the  measure  you  have  thus 
far  in  vain  proposed  effective.  The  action  advised  is  as 
follows :  to  render  the  study  of  medical  jurisprudence,  in 
which  insanity  holds  so  important  a  place,  more  prominent 
at  our  medical  schools  than  it  has  ever  yet  been. 

"  Of  the  propriety  of  such  a  step,  few  of  our  teachers  have 
ever  doubted.  It  has  more  than  once  been  urged  upon  this 
Association,  in  the  valuable  reports  upon  the  subject  pre- 
sented to  you  by  Drs.  Coventry,  of  Utica,  and  Reese,  of  New 
York  City.  Now  that  the  Association  has  again  risen,  with 
more  than  youthful  vigor,  from  the  ashes  of  the  past,  it 
should  be  no  vain  hope  that  the  wise  suggestions  made  to 
you  nearly  ten  years  since  may  be  carried  into  effect.  Long 
ago  it  was  the  complaint  of  that  Nestor  of  American  psy- 
chological writers,  Dr.  Pliny  Earle,  that  this  '  subject  of 
insanity  does  not  enter  into_  the  programme  of  lectures  in 
any  of  our  leading  medical  schools.  It  is  safe,  perhaps,  to 
assert,'  he  says,  '  that  not  one  in  ten  of  the  graduates  of  those 
schools  has  ever  read  a  treatise  upon  mental  disorders.' 
'  Indeed,'  says  one  of  3'our  reporters  to  whom  I  have  re- 
ferred, *  the  department  of  medical  jurisprudence  itself  is 
either  wholly  ignored  in  the  curriculum  of  our  universities 
and  colleges,  or  merely  appended  to  some  other  chair  or 
chairs,  by  way  of  formal  recognition,  and  this,  for  the  most 
part,  5/a/  notniyiis  utnbra.''  And  again:  'The  demands  of 
our  civil  and  criminal  courts  all  over  the  land,  for  competent 
and  intelligent  medical  testimony,  must  be  met  by  raising 
up  an  army  of  experts  in  every  department  of  medical  juris- 
prudence, and  especially  on  this  important  topic  of  mental 
aberration.  Else  the  ignorance  of  too  manj^  physicians, 
displayed  before  the  courts  and  juries,  may  lead  to  the 
undervaluation,  if  not  the  rejection,  of  medical  evidence  in 
all  such  cases.'  * 

*  Report  on  Moral  Insanity  in  its  Relations  to  Medical  Jurisprudence 
Transactions  of  the  American  Medical  Association,   1858. 


232  REFLEX    IXSAXTTY 

*'  Attempts  have  been  made,  it  is  true,  to  initiate  a  change, 
but,  at  best,  they  have  been  but  feeble  and  imperfect.  At 
Harvard  University  the  special  subject  of  insanity  is  lectured 
upon  by  Dr.  Tyler,  and,  at  Pittsfield,  Dr.  Earle  was  called  not 
long  since  to  a  similar  duty,  until  forbidden  to  pursue  the  sub- 
ject by  the  trustees  of  his  asylum,  upon  the  ground  that  it  took 
him  from  the  more  legitimate  offices  of  his  position  as 
superintendent.  As  yet  the  evil  upon  which  he  himself  so 
forcibly  commented  remains  unchanged.  In  but  a  few  of 
our  schools,  whether  of  medicine  or  of  law,  is  the  important 
subject  of  medical  jurisprudence  viewed  with  a  tithe  of  the 
interest  it  deserves;  in  others,  if  touched  upon  at  all,  it  is 
only  as  an  appendage,  like  a  caudal  fin,  as  has  well  been 
said  by  one  of  its  own  professors,  to  some  other  chair,  im- 
properly considered  as  of  more  importance.  This  indiffer- 
ence has,  no  doubt,  in  part  been  owing  to  the  lack  of 
competent  instructors,  who,  to  be  properly  fitted  for  their 
task,  should  themselves  be  masters  alike  of  medicine  and  of 
the  law.  Teachers,  however,  would  have  been  long  since 
forthcoming,  had  the  colleges  called  for  them.  As  a  strong 
proof  of  the  argument  now  made,  let  your  delegate  state  that 
in  a  letter  lately  received  from  that  justly  eminent  and  very 
competent  instructor,  Dr.  John  Ordronaux,  of  New  York, 
the  fact  is  mentioned  that  this  gentleman  now  lectures  upon 
medical  jurisprudence  in  no  less  than  five  professional 
schools,  to  wit,  two  law  and  three  medical ;  and  these,  it  is 
perhaps  not  too  much  to  say,  are  almost  the  only  instances 
in  which  this  science  is  as  yet  at  all  properly  taught  in  this 
country. 

"  There  is  no  class  of  experts  against  whom  the  bolts  of 
legal  practitioners,  alike  counsel  and  judges,  have  been  so 
unsparingly  hurled,  as  against  those  claiming  to  speak  as 
medical  jurists.  Particularly  does  this  occur  in  cases  of 
insanity;  and  in  none  has  so  much  real  damage  been  done 
to  the  profession,  not  always,  either,  with  entire  injustice. 
The  exigencies  of  the  case,  aggressive  and  defensive,  have 
been  so  great,  that  the  subject  has  lately  been  taken  in  hand, 
with  a  view  to  decided  action,  by  one  of  the  highest  courts 


IN   WOMEN.  233 

of  professional  appeal  in  the  country,  the  American  Acade- 
my of  Arts  and  Sciences,  the  whole  matter  having  been 
under  examination  by  a  committee,  of  which  the  Chief 
Justice  of  Massachusetts  was  chairman,  and  of  which  your 
delegate  has  had  the  honor  to  be  a  member.  As  parties 
deeply  interested  in  any  movement  that  can  better  your- 
selves and  advance  the  interests  of  the  profession,  it  lies 
with  you  to  assist  in  this  work. 

"Your  delegate  would  therefore,  while  trespassing  no 
longer  upon  your  patience  by  argument,  offer  for  adoption 
two  mutually  dependent  resolutions,  the  second  of  them 
being  based,  he  would  recall  to  your  recollection,  upon  action 
taken  at  your  last  meeting,  at  the  suggestion  of  Dr.  Edward 
Jarvis,  the  well-known  statistical  psychologist,  in  accordance 
with  which  a  Section  of  Psychological  Medicine,  Intended 
more  particularly  for  the  reception  of  the  superintendents, 
was  organized  by  this  Association.  It  is  a  source  of  great 
satisfaction  that  yesterday,  for  the  first  time,  the  new  section 
was  formally  convened.  The  high  character  of  the  half 
dozen  gentlemen,  all  of  them  connected  with  the  specialty 
of  insanity,  who  took  part  in  its  deliberations,  and  the  im- 
portant work  that  they  accomplished,  which  was  no  less 
than  assigning  a  special  scientific  investigation  to  the  most 
celebrated  member  of  their  fraternity.  Dr.  Isaac  Ray,  are 
an  earnest  that  your  interests  in  this  direction  will  not  be 
allowed  to  languish.  More  is  required,  however,  than  has 
thus  far  been  effected.  It  is  necessary  that  the  great  body 
of  superintendents  should  convene  at  the  same  time  and 
place  with  yourselves,  and  thus,  without  in  reality  interfering 
with  their  enjoyment  and  their  consentaneousness  of  action, 
that  their  interests  should  become  more  clearly  identified 
with  your  own. 

"  The  resolutions  now  offered  are  the  following;  for  their 
passage  still  additional  arguments  would  have  been  pre- 
sented, had  such  seemed  necessary  :  — 

"  I.  Resolved^  That  the  Association  recommend  to  the 
several  medical  and  law  schools  of  the  country  the  establish- 
ment of  an  independent  chair  of  medical  jurisprudence,  to 


234 


REFLEX    INSANITY 


be  filled,  if  possible,  by  teachers  who  have  studied  both  law 
and  medicine;  attendance  upon  one  full  course  of  lectures 
from  whom  shall  be  deemed  necessary  before  the  medical 
degree  is  conferred. 

"  2.  Resolved,  That  while  this  Association  regrets  that  the 
Association  of  Superintendents  of  American  Asylums  for  the 
Insane  has  not  yet  thought  fit  to  unite  itself  more  closely 
with  the  representative  body  of  American  physicians,  it  still 
is  of  opinion  that  such  union  is  for  their  mutual  and  re- 
ciprocal advantage,  and  that  it  ought  to  be  effected  without 
further  delay. 

"All  of  which  is  respectfully  submitted." 

The  resolutions  above  presented  were  unanimously 
adopted  by  the  Association. 

As  the  present  leaf  of  this  book  is  passing  through 
the  press,  I  have  received  a  most  interesting  com- 
mentary upon  its  last  few  pages.  At  the  annual 
meeting  for  the  present  year  (1870)  of  the  Association 
of  Medical  Superintendents  of  American  Asylums 
for  the  Insane,  the  official  report  *  of  which  has  just 
reached  me,  these  gentlemen  were  assured  by  the 
delegate  from  the  American  Medical  Association, 
Dr.  John  L.  Atlee,  of  Pennsylvania,  that  their  union 
with  the  General  Association  would  be  impolitic, 
both  for  themselves  and  the  profession  at  large. 
"  We  have  enough  to  do,"  said  Dr.  Atlee,  "  in  de- 
voting onr  time  to  the  other  departments  of  medicine, 
without  including  the  subject  of  insanity,"  —  a  remark 
as  applicable  to  all  other  classes  of  disease  whatso- 

•  American  Journal  of  Insanity,  October,  1870,  p.  129. 


IN   WOMEN.  235 

ever.  Under  these  circumstances,  Dr.  Atlee  was,  of 
course,  congratulated  by  the  superintendents  for  his 
alleged  good  sense,  and  his  remarks  will,  doubtless, 
be  still  further  lauded  by  Dr.  Tyler,  of  the  Somervilk 
Asylum,  in  his  report  upon  the  subject,  that  his  recent 
illness  has  delayed  until  next  year. 

Notwithstanding  all  this,  I  still  submit  that  the 
meetings  of  the  two  Associations,  so  long  as  they 
shall  remain  distinct,  should  at  least  be  held  at  the 
same  place  each  year,  and  nearly  simultaneously, 
the  one  immediately  preceding  or  following  the  other. 
In  the  immediate  vicinity  of  all  our  large  cities  there 
are  now  insane  asylums,  to  visit  which  it  is  naturally 
so  pleasant  to  superintendents. 

It  must  not  be  forgotten,  moreover,  that  Dr.  Atlee 
is,  and  has  long  been,  a  manager  of  one  of  the  Penn- 
sylvania State  Asylums,  and  that,  as  he  is  therefore 
necessarily  identified  in  feeling,  as  he  has  indeed 
shown  himself  to  be,  with  the  members  of  the  spe- 
cialty, his  opinion  upon  the  question  referred  to  must 
be  received  with  a  good  deal  of  hesitancy. 

The  remarks  made  at  the  same  meeting,  upon  the 
relations  of  uterine  disease  to  insanity,  by  Dr.  James 
P.  White,  of  Buffalo,  also  a  manager  of  a  State  Asy- 
lum, and  President  of  its  Board,  are  in  every  way  to 
be  admired.  Professor  White,  like  Dr.  Atlee,  is  well 
known  as  one  of  the  best  gynaecologists  in  the  coun- 
try ;  and  from  the  efforts  he  has  made,  through  the 


236  REFLEX    INSANITY    IN    WOMEN. 

American  Medical  Association,  to  procure  the  estab- 
lishment of  professorships  of  mental  disease  at  all 
our  medical  colleges,  his  opinions  cannot  but  have 
great  weight  with  those  in  charge  of  asylums. 

Thus  it  will  be  seen  that  there  are  signs  that  the 
great  reform  in  the  treatment  of  the  female  insane, 
for  which  we  have  so  long  been  laboring,  will,  at  no 
distant  day,  become  accomplished. 


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